HomeMy WebLinkAbout19. 15-485NOVEMBER 10, 2015 15-485 RESOLUTION
(CARRIED__7-0______LOST________LAID OVER________WITHDRAWN________)
PURPOSE: APPROVE EMPLOYEE HEALTH INSURANCE AGREEMENT WITH
WISCONSIN COUNTIES ASSOCIATION (WCA)/ GROUP HEALTH
TRUST (GHT) AND DENTAL AND VISION INSURANCE
AGREEMENTS WITH DELTA DENTAL OF WISCONSIN FOR
REGULAR NON-REPRESENTED EMPLOYEES
INITIATED BY: ADMINISTRATIVE SERVICES
WHEREAS, the City of Oshkosh requested proposals for Employee Health
Insurance for 2016; and
WHEREAS, the proposal submitted by Wisconsin Counties Association
(WCA)/Group Health Trust (GHT) meets the requirements of the request for proposals and
will allow the City of Oshkosh to realize cost savings over the current City plan; and
WHEREAS, in order to preserve a competitive level of benefits for employees, staff
is recommending using a portion of the savings to fund a portion of a dental plan and to
offer employees the additional option of participating at their own cost in a vision plan; and
WHEREAS, Delta Dental of Wisconsin offers the most advantageous Dental and
Vision plans to meet the City’s requirements.
NOW, THEREFORE, BE IT RESOLVED by the Common Council of the City of
Oshkosh that the proper City officials are hereby authorized to enter into and take those
steps necessary to implement an appropriate agreement with Wisconsin Counties
Association (WCA)/Group Health Trust (GHT) for participation in the WCA/GHT health
benefit plans to be offered to the City’s employees in substantially the same form as the
attached agreement, any changes in the execution copy being deemed approved by their
signatures.
BE IT FURTHER RESOLVED that the proper City officials are hereby authorized to
make application to Delta Dental of Wisconsin for group participation in dental and vision
plans by regular non-represented employees and when such application is approved to
enter into and take those steps necessary to implement an appropriate agreement for such
purposes.
BE IT FURTHER RESOLVED that money for this purpose is hereby appropriated
from:
Acct. No. XXX-XXXX-6306-XXXXX Health Insurance
XXX-XXXX-6308-XXXXX Dental Insurance
CITY HALL
215 Church Avenue
P.O. Box 1130
Oshkosh, Wisconsin City of Oshkosh
54903-1130
�
�
O.fHKOlH
TO: Honorable Mayor and Members of the Common Council
FROM: John Fitzpatrick, Assistant City Manager/Director of Administrative Services
DATE: November 5, 2015
RE: Employee Health, Dental, and Vision Insurance Agreements
BACKGROUND
Through direction received from Council in our most recent health insurance
workshop held on September 8, 2015, city staff and Associated Financial Group
(AFG) have been finalizing the agreements necessary to establish a relationship
with Wisconsin Counties Association (WCA)/Group Health Trust (GHT), Delta
Dental of Wisconsin and Delta Vision of Wisconsir�a as vendors for the City
beginning in 2016.
ANALYSIS
After evaluating current medical plan costs the decision was made to conduct a
comprehensive request for proposals (RFP). The outcome of the RFP showed a
significant financial s�vings by moving from their current partially self-fu�ded model,
to WCA/GHT a fully insured plan. In addition, to reduce the impact of the 2018
Cadillac Tax the City is also able to transfer costs currently paid to the medical plan
and a fund dental plan.
The dental plan will be 85% employer contribution and 15% employee
contribution. The vendor with the most effective plan for the City was Delta
Dental of Wisconsin. In addition, the City will offer a vision program which will be
fully funded through employee contribution. At this time, the dental and vision
programs will only be offered to non-represented employees. The Public Safety
and Transit unions have elected not to participate in these programs at this time.
The WCA/GHT agreement/application is for a two year duration, with a"not to
exceed" premium increase provision of 8%, included in the WCA/GHT agreement
for 2017: The Delta agreements/applications are for 2016 only.
�`�1
FISCAL IMPACT
Even after factoring in the $ 209,700 employer cost for the dental insurance
portion of this proposal, staff is estimating savings of $1,274,600 for our
combined health/dental program in 2016.
As reported at the September 8 workshop, AFG has recalculated the projected
liability for the city's annual ACA "Cadillac Tax", scheduled to begin in 2018.
With the adoption of this new plan and the addition of dental insurance, the city's
liability is projected to be reduced from $676,000 to $22,000. Through the
creation of an employee focus group on health insurance, staff's plan is to make
the necessary plan changes to eliminate any ACA "Cadillac Tax" liability in 2018
and beyond. The move to the WCA/GHT plan will get us on our way to achieve
this goal.
RECOMMENDATION
Based on the analysis conducted, as well as the discussion and direction that
occurred in the Council Workshop held on September 8, 2015, staff recommends
approvals for 2016-20�7 health, the 2016 dental and the 2016 vision insurance
agreement/applications.
Respectfully Submitted,
�.
Approved:
i
' :
John M. Fitzpatrick Mark A. Rohloff
Assistant City Manager / City Manager
Director of Administrative Services
Attachments: WCA Group Health Trust Participation Agreement
Delta Dental & Vision Group Applications
cc:
Pam Resch, HR Manager
2
WCA GROUP HEALTH TRUST
PARTICIPATION AGREEMENT
(2015 EDITION)
This Participation Agreement ("Agreement") is entered into and made effective as of
January ls`, 2016 by and between WCA Group Health Trust ("Trust") and the City of Oshkosh,
a Wisconsin municipal corporation ("Member").
WHEREAS, the Wisconsin Counties Association, by a Trust Agreement dated January 3, 1991,
as amended and restated from time to time (the "Trust Agreement"), created the Trust far
purposes of providing certain health and welfare benefit plans to Participating Members. The
Member acknowledges that the Trust is not an insurance company and that any Plans made
available through the Trust are jointly self-funded by the Participating Members;
WHEREAS, the Trust has created one or more Plans to provide certain employee benefits to the
employees of Participating Members and their eligible spouses and dependents;
WHEREAS, the Member seeks to provide its Employees and their eligible spouses and
dependents with various employee benefits under one or more of the Plans; and
WHEREAS, the Member wishes to participate in the Trust and obtain coverage through one or
more Plans offered by the Trust in accordance with the terms and conditions of this Agreement,
the Trust Agreement and the Plans.
THEREFORE, IT IS HEREBY AGREED:
1. Definitions. As used in this Agreement:
a) "Coverage Period" with respect to any Plan means the dates of coverage set forth in
the Plan during which coverage is made available to Employees and their eligible spouses
and dependents in accordance with the terms of the Plan.
b) `Bmployee" means an individual parti�;ipatin� in a Plan who is an active officer or
employee of the Member, a retired officer or employee of the Member, a former officer
or employee of the Member who is eligible for continuation of coverage under the
Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) or section 632.897,
Wisconsin Statutes, ar an officer or employee on leave under the Family and Medical
Leave Act of 1993 or section 103.10, Wisconsin Statutes, all as amended from time to
time.
Participation Agreement (2015 Edition)
Page 2
c) "Participating Member" means any county, multi-county governmental unit, city,
village, town, school district or any other governmental or quasi-governmental entity or
agency eligible to participate and participating in the Trust.
d) "Plan" or "Plans" means any employee health and welfare benefit plan ar plans
(including any schedules, attachments, and amendments) issued to the Member by the
Trust and administered by the Trust Board including, without limitation, its agents,
pursuant to the terms of the Trust Agreement and this Agreement. In the event of any
conflict between this Agreement and a Plan, the terms of the Plan shall prevail.
e) "Trust Board" means the Board of Trustees of the Trust.
� "Year" means calendar year.
2. Participation by Member. Upon execution of this Agreement and payment of all
contributions by Member as provided below, the Member shall be automatically enrolled
as a participant in the Trust (to the eYtent the Member was not previously enrolled as a
participant in the Trust pursuant to any prior Participation Agreement). The Trust shall
offer one or more Plans, as amended from time to time, which when issued to the
Member shall be deemed incorporated by reference into this Agreement.
3. Obligations of Member and Employees. The Member and its Employees shall comply
fully with all provisions of this Agreement, the Plans and the Trust Agreement which
impose an obligation on the Meinber or its Employees, as the case may be.
4. Obligations of the Trust. The Trust shall comply fully with all provisions of this
Agreement, the Plans and the Trust Agreement which impose an obligation on the Trust.
5. Contributions by Member or Employees. The Member or its Employees shall pay all
premiums and charges which the Member or its Employees are required to pay according
to the terms of this Agreement or the Plans, as the case may be.
6. Offer of Participation. Participation in a Plan shall be offered to all Employees in
eligible classes as defined in the Plan.
7. Minimum Participation Level. If, upon renewal of any Plan, fewer than 75 percent of the
Member's eligible Employees who participated in the Plan in the preceding 365 days are
participating in a Plan at renewal, the Trust, at its option, may:
a) Re-rate the Member based on actual participation levels and, if necessary, adjust the
Member's premium payments as appropriate.
b) Terminate the Plan and the Member's participation in the Trust, on sixty days prior
written notice to the Member, instead of or in addition to adjusting the premium for
the remaining Coverage Period.
Partici}�ation A�reement (2015 Edition)
Page 3
c) Decline to offer the Plan to the Member if the Coverage Period has not yet begun.
8. Effective Date. This Participation Agreement shall be effective as of January ls`, 2016
and shall continue in full force and effect through December 31, 2016. Thereafter, this
Agreement shall automatically renew for additional one-year terms unless otherwise
terminated in accordance with Paragraph 9. Termination of this Agreement shall
automatically terminate the Member's participation in the Trust but shall not relieve the
parties from any obligations under this Agreement, the Plans, or the Trust Agreement to
the extent such obligations arise or relate to periods prior to the date of termination and
have not been satisfied as of the date thereof. Any Participation Agreement entered into
between the parties prior to January 1 st shall remain in effect and shall govern any
periods and claims occurring prior to January 1 st.
9. Termination. The Member may terminate this Agreement and its participation in the
Trust at the end of any Coverage Period by giving the Trust at least sixty days written
notice prior to the last date of the applicable Coverage Period. The notice shall be
deemed given when actually received by the Trust at its principal office. A Member
terminating its participation in the Trust shall not receive any return on contribution,
return on capital or other dividends declared with respect to any Year in which the
Member was participating in the Trust. The Trust may terminate this Agreement and the
Member's participation in the Trust at any time if the Member fails to pay any premiums
or breaches any other obligation of this Agreement, the Plans or the Trust Agreement.
10. Claims Run-Out.
a) If the Member terminates its participation in the Trust by giving the Trust sixty days
prior written notice, the Trust shall not be required to pay any claim filed more than
twelve months after the effective date of termination of the Member's participation in
the Trust.
b) If the Member terminates its participation in the Trust without giving the Trust sixty
days prior written notice, the Trust shall not be required to pay any claim filed with
the Trust after the effective date of termination or the last date for which the premium
was fully paid, whichever is earlier.
1 L Information Provided Fo� Bidding Purposes. The Member shall notify the Trust of the
Member's intention to solicit bids for employee benefits at least ninety days before the
period for which the Member will solicit bids. On receipt of timely notice, the Trust, at
its expense, shall prepare and mail one copy of the following information to the Member,
subject to any limitations imposed by applicable law:
a) Census of participating Employees and their covered spouses and dependents,
including age, sex and type of Plan.
Participation t�greement (�20�15 Edition)
Pa�e 4
b) Premiums paid and claims incurred under the Member's Plans for the previous two
annual Coverage Periods and the part of the current annual Coverage Period for
which information is available.
c) Information pertaining to any claim in excess of $75,000 pertaining to an individual
covered by the Member's Plans during the previous two annual Coverage Periods and
the part of the current annual Coverage Period for which information is available,
subject to applicable state and federal laws governing medical confidentiality.
The Trust shall provide, far a reasonable fee to be determined by the Trust, any
additional copies of this information requested by the Member and, if available, any
special claims reports requested by the Member. The Trust shall not be required to
disclose the name of any claimant or information by which the claimant could be
identified and shall not be required to make any disclosure prohibited by law.
12. Dicty to Cooperate. Member agrees to cooperate with the Trust including, without
limitation, a�ents of the Trust, with respect to any and all reasonable requests of the Trust
in relation to the parties' duties and obligations under this Agreement, the Trust
Agreement, any prior Participation Agreement between the parties and any Plans
incorporated therein.
13. Entire Agreement. This Agreement, any Plans incorporated into this Agreement, the
Trust Agreement, any prior Participation Agreement between the parties and any Plans
incorporated therein constitute the entire a�reement between the parties and supersede all
prior negotiations concerning the same subject.
14. Severczbility. If any provision of this Agreement is held to be illegal, invalid, or
unenforceable under any present or future law, and if the rights or obligations of any
party under this Agreement will not be materially and adversely affected thereby, (a) such
provision will be fully severable, (b) this Agreement will be construed and enforced as if
such illegal, invalid, or unenfarceable provision had never comprised a part hereof, (c)
the remaining provisions of this Agreement will remain in full force and effect and will
not be affected by the illegal, invalid, or unenforceable provision or by its severance here
from, and (d) in lieu of such illegal, invalid, or unenforceable provision, there will be
added automatically as a part of this Agreement, a legal, valid, and enforceable provision
as similar in terms��to sueh illegal, invalid, or unenforceable provision as may be possible.
15. Governing Law. This Agreement shall be governed by and construed in accordance with
the laws of the State of Wisconsin.
[Remainder of this page left blankJ
Participation A�r.eement (2015 Edition)
Page 5
IN WITNESS HEREOF, the parties have caused this Agreement to be executed by their duly
authorized representatives on the date(s) set forth below.
CITY OF OSHKOSH
BY
Signature
NAME
Print or Type
TITLE
Print or Type
DATE
WCA GROUP HEALTH TRUST
�.
Michael Lamont
Assistant Secretary, WCA GHT
DATE
Participation A�eemerx�t,(2015�.Edition�
Page 6
CITY OF OSHKOSH
(1/01/16 —12/31/16)
Medical
Single $ 755.00
Limited Family $1,510.00
Family $1,888.00
WCA Group Health Trust wili provide a second year rate guarantee not to exceed 8%
the second year of this contract.
WCA Group Health Trust will provide funding up to $200,000 for the Three Waves Clinic
and pay for on behalf of the City as long as they are a participant in the WCA Group Health
Trust. We will also pay for the health risk assessments for any covered employee
and spouse covered by the WCA Group Health Trust.
$20,000 Wellness Grant
$30,000 Health Risk Assessments
Our program does include the COBRA Administration & Retiree Administration.
Medical coverage will be provided to the City's counsel, Bradley Priebe, lawful spouse, and
eligible dependents, as if he were a regular full-time city employee. Such coverage shall
continue until such time as he is no longer is under contract with the City.
WCA Group Health Trust is willing to include the consulting fees payable to Associated
Financial Group in our renewal for 2017.
�
Delta Dental of Wiscansin
Fu��� lnsur�d -- Group Applica�ion
Dalta Dental of Wisconsln Is unabte to accapt thfs document with any changes, cross•ouis, white•outs, etc., unless the person slgning
the applfcatlon lnitfals those changes. •
In order to honor the requested effective date of coverage, aff materiats must be received by Delta Denta! no later than flve buslness
days prlor to the requested effective date. De{ta bental reserves the rEght to deslgnate the effective date if materials are not
reca(ved withln this timeframe. Please print clearly.
-------• •---------•-------•--•-------• ................. ......• •-------------•----•-•---. • •------•-----------•---•--•-••---......................
R.EQUIR�MENTS T� �NR4LL A NEW �lVIPi�OYER
❑ A completed employer appiicatlan form
❑ A chec4 for the tirst month's premium, and a tompletad ACH farm (lfACN ls salecied)
❑ A copy of the sold proposal out(lning benefits
❑ Completed enroflment forms (Enro!lment forms may not be required if el(gibifrty reporting method is spreadsheet or eJectronfcj
----------------•---�---•---�-�---••--------•-----..__...__..........-•-•--•-
5TEP 1 -- �MPLOY�� lNFORMATION
Citv of Osi�kasl� �
Lagai 8uslness Name
DE3A {il dlffe�ent?
21S Church Aventte, Raom 401
INFORMATION liV THIS BOX 1S REQUIRED
Total Number of Ellgible £mployees; 560
(lnctude completed walvers ior those rtot enrofling)
Total Numt�er of �mployaes Enrolling: TBD
Raquestad Effecifve Date; Januaty l, 201G
Address PO 8ox
Osl�kosh �VI 5�1903-1130
City Skate Zfp
�20-236-slit �
Cifv Govcrnmeiit � 912�-04
Natvre o Buslness S1C ca e
None �
revlous enta amer
P�m Resch � Hum�n Rcsourccs tillna�er
Bennfit Contad Namo 8enaiit Contad Titla
920-23b-5111 preschnn,ci,osllkosh.ivi.us
8ene(it Contact Phona 8enefit Confact Emai
Kiin Knutz<3 Beneiits CoordiuRtor
BIIIIng Conlact iJame Csilling Contact Tit e
920-235-Si33 kkautzl(r�ci.ostikosh.�vi,us
BiNing Contact Phono fiilling Contact Emal .
Groap Health Ti1�st �s of 1/1/16
urrent ea t arr�er
Paymont Mothad: �ACN (See page 3J Q Chec!< (A check l�om the gro�p for tho first month's p�emfvm fs iequlred for both payntent mothocls)
eilling Oefivery Iviethod: ❑ Paper [� Fax QEroaif ff emall, spe<ify ema(I address: iC�Cfllll2;1 Cl,Cl,oshkosh,wi.l1S
i of �� f �Uy�;
STEi' 2 - Pi.AN D�SIGN
(Important: This section must be completed by the �c ent or t��emploT_er.
All information must be provided. Please print dearly.
]. S818ct
tW0•t�9 ,
three•tier,
or fountier
2, Fip In
empfoyar
contribution
porcentages
3. Fill In rates
, Q Two-Tier ;
i
- _? `
-``":`.��Employer,; °Io �
''.Conld6uVOn:�
- - Employ�ea Farr.i�
R�tati�' 4� �
.-.- --, ---_'.'..� Ernploy�ta fam±/
For quostions on thfs appilcation,
contact your agont or call our Sales
departmQnt at 800-236-3713 or
email saiosWdel#adentalwl,com
. �
'' ❑ Th.ree 71ar -, ;,:i
OJ °lo g� % �� %
EmpJ7wa orMore
Empoyrr , Emp./CepenNnt Gvp�nd�nls
� 30.86 g 62,59 � 117.99
Emp. / Two ot Mera
Fmployeo Fmp./OeFerdmt Dopend.nts
;' : _ '. � Faur-Tler - -
. . . : , , . .. . .: . . .
_.
.:. ._ .... ._- _... . ... , . -..: _
. ,,; ; ._ • �i
=�-:�;'Employir, o�a • �/a � % °�
`:CoptribWJon; ; �
Ernployae Emp./Spovi• Er�p./Ch'�kGenJ fMP./SPCU59%C71IAI/2�f
= R,�ei': 3 3 $ $
_, . ......, _ Fmployzv Smp./Spo��o � Emp./Ch'Gi¢on) Emp./Spovea/ChJdf�en)
..........................'-'..._.__.....---'-----•--------'---..-'--._......................_..._._........................_._._....._........
Ptait Infdrmatian `
Plan•dasign number: QQ3��6
(Note: Plan•ciestgn number can be foundlrt the apper lelt
corne� of the proposa!)
Benefhs-accumulation period;
❑ Contract yoar
Q Calerdar yaar
Coverage for surglcal dental procedures:
Q Medleai pr)mary, dental secondary
❑ Covered in madicai pian only {please supplyhandbook)
❑ Covered tn dental plan only
❑ Covered In dental plan only if axc!uded 6y med(cal ,
-----• ................� _.-----------.__�.------•---•----•-------•----°�---..............,....-----•----..................•-• • •°--• • • •--•. _...
Emp[oyee Eligibifity
Employeas �ro dligfblo fo't coverage on {select one):
❑ Date of hire (no waJting perfodj
❑ 1st of the month foliowing the date of hire
�ef�l�ameait�.foAew�ag.-�--daysaE�a�claie.o(.ki�a
l�Yl ,� da s e I ent fter date of hire
r� �lw
kmployea tarms o( oUgibilily:
❑.30 hours mtnimum avarege hours worfced per wse'c
Q Other (speci(y) 1�6 ��►' J Q� �
o�.d r �l �S r2�iV i��
7armtrtalion datu for employees;
❑ Date of termination ❑ End of manth follo�ving termination
Q Other (specilyj
Dependenis/stadants are covered to:
'Q 8frthdate [] End o1 monih ioilcwing blrthdate
Coverage fordomestft partners:
❑ Yes ONo
2 of d � Pc��JP
If the day of becoming an employee is frorn the first to the fifth day of the month, coverage is effective
the first calendar day of the next rnonth provided you are in active status and/or employed on that date.
lf the day of becaming an employee is after the fifth calendar day of the month, coverage is effective the
first day of the month after 31 days following the date of becoming an employee.
STEP 3 - AGENT INFORMATI�N
Jan Sta�a Associnted Fin�nci�l GrouU 91-21$9930
Agont Nams Agency Name Agency fed. ID No.
711 Eisenitotiver Drive, Kimbe��iv �VI S�#I3G ian.stase a,�ssoci�tedfcnancinlsroun.corn
Address Emoll
920-731-O�i00 I�VILicense #9631SG
Phone Soclal Security No, ['JVPN Gtfcenso No. �ederaffyFacilitated Markatplaca Uset !D
!f comm)sslon is to bo pafd to somoone othar than the above, pfease slate:
Not Anulicnbte - Net of Cot3unissions
Namo
Cansultant's Nama Phono
Address ' Email
STEP 4 -AC:H FINANClNG AGREEM�NT {QPTl�NAL)
A�tomated clearinqhaus3 (ACH) iransfor of funds Is a�a(e, easy, artd effective way ta ensure proper funding of thu group's accaun6 To sot up an ACH t�ansia ,
ple�so eomptete tha fn(ormt�lon below. Thls fnformouon fs only requlrad for grvups paying vla AGN. Nolo: Fof fullyiawred plans wilh ACH, a chack for tha fint
maoth's premlum is requlredwfth Ihe appllcalfcn and ihis ACH (arm,
Contact Name Contact Phone
Coniact Emall � Secondary Coniact Emaii J
Depository Name poposllory TransitlLYBA No.
Account iVame Account Vo. � Savings or � Checking
I(wa) horaby authori:a Dslia Oental of Wisconsin, fnc., herelnafter calfad Company, lo (nillate debit entrles and to (nitiate, if necessary, ctedit anlrfas ond
adjustmenta far any dabit emrle:ln arror to my (cur) account and the flnandal instltutlon Indlcated above, herein caped Daposltory, to debft and/ar credit tha same
eu<h atcount, Thts authority Is to remain in fulf fmce and effecl unti) Company has recaived vnttten notllfcallon from me {or eithei ot ue) of Its tarminatfon in such
tlme and fn such manner as ta afford Company and Daposttory a reasonable oppar Wnfty to act an it.
fVame (Vamo
Slgnature Date Signature Oata
..............................• •---...._..---°-�--,............-•-•--• �-°---.........-•-------••------•-------°-•---------._._..............
STEP 5 � �MPL4YER AGR�EiV��NT
In maklnp tfils applicaticn to Deha Oerttaf of Vrsconsln �CDY� for group denlzl coveiage undat thlspragram, tAe Graup agreas artJ �mderst:r.ds Ihls applicalion vrill
become pa�t of the Co�tract uxacuted by an authorized offlcrr of CDW. Itls agreed that the eoverage requested fs sub;act io ihn approval ot DD�Nand that no agent or
�epiesentative has authority tomake o� modilytRts appllcatEon fw covcrage, 7ho Group herehy certi0es that alI ot tha above in(ormotton is t�ue and correet. Tfie Group
unde�stands that covorago vdli r.ot bo of(ecUvo until qvostlons regarding eligiblNty (or covoraga have bean sa�lsfa<OoAly rosolved. Tho Group agree9 to De bovnJ bythe
term� of the �ont�act Issued by DDW to the extenl it does not conR�ct vdth this applkatton. Misrepreseniation o( submitted data will cau�e thls appft<atton and suhsaquent
ContradtobelV!!�A /� l��i � /� � �iL��� �/1!1//lfl��U . f /�Y1.1�.!'��1i'I.VIJ!
me
Slgna�ure
Approval o! coverage Fs contingent upon UnBerSvr! ing�cte tartc� ���v
7it
3 of �i f puge
STEP 6 -- lMPLEMENTATION CHECKLIST
1. Would you like Daita Dantal to assist with empfoyae meetings7
Q Yes Q No
2. Do you require biUing by subdlvfslon? {mar� ail that apply)
Q C06RA [� Other (attach lrsi and bitling contact In(ormatlon) ❑ AJ/A
3. Payment method:
❑ ACH (if ACH, com�lete Step 4 on Page 3} 0 Checic
A. Biflinc� deltvery mathod;
Q Emall (spur'tyomalf address) kkalifZ3 C1,CI.OS}ll{OSI1.�V1.11S �apar QFax #
5. Entpioyeas are requlred to havo an fdentlilcation number !or submitting or transmitti�g enroliment or otlier fn{ormatton to Delta Dantal.
Who should asslgn that ID number7 !rf Delta Renral esoigns the 1D numbsr, SSN rs reGutrod on Ihe enrolfinent tronm�lssiort►
QQelta Dantal ❑ Employer
6. Enroflment transmissian:
❑ Indudad � Electronic Rle Q Paper forms ❑ Sproadshaa!
Estfmated recaipt date of elecironic rle, paper forms, or spreads3�eet J
0
-----•-•--...--•-----•----°•-------°------------------........_..-•--•--••-•--•°-°•--- °°--------._...._.................._....---•-•-••--
57�P 7 - SUSMIT APPi.ICATIOU
Plaase submit aoplication with ortrollmont to your Delta Dental rspresentative or mafl t�,
Delia Dental of Wisconsin
AtSn: Salos
280i Hoover Rd„ PO eox 828
Stovans Point, WI 5448i•0828
fimali: <_ale<�dekadental��ri.com
Fax: 715-343•7623
lull�irisuredgrouf�upp
� 02.2U 1 S
F702•0215
4 of d � �age
Delta Dental of Wisconsin
�����Vision°-- Group App�ica�ion
Wyssta insurance Company, a whollyowned subsidlary of pelta Dental of Wlsconsin, is unable to actapt ihls document with any
changes, cross-outs, white•outs, etc, to the answers given unless the person s'.gn(ng the applicatlon in(tials ali such changos.
In order to honor the requested effect(ve date oi coverage, aN materlals must 6e rece(ved by 4Vyssta no iater than flve buslness days
prior to the requested effective dato. W�ssta reserves the rfght to deslgnate the effective data H materials are not received within
th(s tfineframe. Pfease print clearfy.
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REQUIREMENTS TO ENROLL. A GROUP
�] This completed group appl(cation form
❑ A checic for the iirst month's premlurn, and it ACN ls thosen, a completed ACN form - detaiEs on page 3
(subsequent pramium payment)
❑ A copy of the sold proposal outlfning benefiis
❑ Completed enroilment forms
(Enro!lment forms may not ba requlred if eligi6ilit/ reporting method is spreadsheat or electronic}
........... ...............• �-•---------------....._......._..-•---•-----•----•-•-..........---.....----------.._.....-----..._..................
Si�P 1 -- GROU� fNFORMATION
City o{ Oshkosh
_aqal busfness name
Tota! number of eilgibfs empioyees: 56Q
pnclude compfeted waivers for thase rrot enrolling)
Tocal number of �employees enroEling: TBQ
Requested eHective data: �anuary 1, 2016
D �A (rf d;lleren U .
215 Church Avenue, Room 401
Address PO 8ox PO 8ox Zfp
Oshkosh W1 54903-113Q
Ctty State lip
920-236-5� 11
8uslness phone Fa:c
City Governrnent 9121-Oh
Nature of business SIC code
Pam Resch Human Resources Manager PI'8SCf1@Cf.oshlcosh.wi.us
Banefit contact name Tilie Emaii
ts iha benefit contact authorixed to handle PHI (P�otected Neafth lnformation}? C] Yes ❑ No
K1m Kautza Senafits Coordinator kkautza@ci.oshkosh.wl,us
Biflina contad name 7itla Emall '
Is the billfng contact authai¢ed to hand]e PHI (Protecisd Nealth lnformatron)1 O Yes C] No
Billing delivery method: � Email (specily) ��aUtZa UG}C€,OS�I�SOSh,VYI,US
No previous carrier
Provious vtsicn carrier (if app!lcabfeJ
Q Paper p Pax
1 of �I � t�i1g8
�
S7EP 2 — PLAN D�SIGN
�Im�ortant: 7hls sectlon must be completed 6y tho a�ent or the pm,nlov�er.
Afl informatfon must be ptovided. Please print ctvarly,
:A[an Inforrrtation<.:I
Network; � Access � Select
Choosa ono piar�, than (i11 In bonafits:
8enafit Piaa Type: O A � H
oComprehensive Plan (Please refer to your qoposaJ to fiJ! frt plan bena6ts)
' Allowance �50 � 950 �Frames/Contactlensesj
Copay 20 / 2D (Exams/Standard Plastfctenses)
Frequancy �? / � 2 / � 2 (Exams / Lenses or Co�tact Lanses / Frames)
CJMaterfals•Oniy Plan A1lowanta (Pfease �e(or toyour proposol to check plan aJlowance)
5150
$2C0
$250
� Nonstandard Plan (Please reler to your proposat to R!!in pl�n benaf,ts)
Altowanca _____ / � (F'rames / Contaci Lansas)
Copay _____ /_____ j�xams/Standard Plasticlensos)
Frequenry _____ /� /_,_,_� (Exams/ Le�ses or Contact tensos! �rames)
Einptoyer:�ontri�OUtton & Rates;:
1. Seleet
two�tier,
three•tler,
er four•ifer
2. Fill in
employvr
cont�ibution
percentagos
3. Fill in rates
- , , O Ttivo Tler .
-- s
.: _ >.i
..,_£mpky�i':, a� %
cCvniriSVHon;�
-- Ernplr/ee Fam1y
�=- Rates �? �` {�
- ti
. ........... . Emp:a/ee Fsm3-f
For questions on thls applicatio�,
contact your agent or calE our Sales
department at 800•23d-3713 or
urnail sales�?daltadenta�wLmm
...: ,Q 7hree�Tier ;. r <-'
� °� � % � %
fmp. / Two or Mae
&nplafea Frnp,/Qepec2ant Dapendants
� 5.65 g 9 a.57 � 15.58
Emp. / 7r.o u Mu�
Employeo EMp./��pmdent Oip�nd�nts
, ;: : �
; '.. ❑ Four Tler E
' �A�oy�ri o�u �I
� ContdSv�lon ' e % %
Errplviee Emp./Spousa Emp./[htd;ren) E.rp./Spoute/Chtd(�en)
_ �;:�
-'���;�:;; $ 3 $ 3
� ....,. �.... , Fmptoye� Emp./Spana Emp./Ch3�{renl FmpJSpou�e/C!�'!d(nn)
7 O{ �� + �p�@
Emp �oyee: Fligf b�f�ty.;. l
Employeas aro ollgiblo ior coverage on (select one): Terminatlon daca for employees:
� Date of hire (no+vaiting pertod) • � Dato of terrninadon' � End ef month follosving termination
� 1st o! the month follow3ng tho data of hire � Other (specify)
O st o 0 o�ving days after date of hire
� Depandents/stadents are coverad to:
ays empfoyment after date of hiro
� Birthdate O Hnd o� month following blrthdate
Empioyao tarms of altg36iliry;
Coverogs for domestle partnors:
� 3U hours minimum avera9e houts wo�ked per week
� Yes a No
Q Other (spacXy) ��oU �,,,�s ����y�.��
... �:r�. �:.h�o� .__�� ���.�-------------------
----------------------- - ......---�--------�-��-----............_.....
STEP 3 - AGENT IN�ORMAT1flN
Jan Siage Associated Financial Group 91-2i89930
Agent name Agenc/ name T.1.N.
711 E+senhawer Drive, Kimberly, WI 54136 lana.hifner@asseciated(inancfalgroup.com
Addross Email
920�731•Qd00 WI Licanse fl968156
Phone Llcense No, Soclai Securily iJo.
I( commfssion Is to bn paid to someone other than the above, pleaso state:
Nof Applicable - Net of Cammissians
Name
name
Address
Emafl
I, N.
...-�--------• ....................................................°---•----•--••------• °----•---------..._._.......---------------•--......_
STEP 4 -- ACH �IN�NCING AGR�EMLNT �
Nota: ForlullyInsured plans with ACH, a check far eho first momNe promlum Is iaqotred wllh tha applleation and thfs ACH torm. Automated clearinghouse
(ACH)1�ansfer of funds (s a safe, easy, and efiective way to enzure �raper iunding oi the G�oup's account. 7a set up an ACti transler, please completa tha
Infarmation below. Thb information Is only required for grovp� paying via ACN.
Contact name Contact phone
Contact email Secondaryconiact ematl
Depository name Depository transit/WBA No.
Account name �ccount No. ❑ Savings or ❑ Checking
I(�vai horobyauthorixe Oelta �ental of Wisconzin, Inc., hereinaftar called Company, ta initlate deblt entries and to iailiate,lFne<essary, <redlt eMrles and
adjuslmants for any doh4t ent�les in arroi to my (aur) account and the Ilnandal insNtwion tndEcated above, hereln eallad Deposftory, to dablt and/er credit the sarne
such accaunt. Thts authority Is to ramaln In iuil (orce and eltect unt1 Company has �ucefved vnitten not�flcailon (rom ma (oi afthar of us} o(its termfnatlon in such
time and [n such manner as to atiord Cornpany and Depositofy a rea�onable opportunity to acl on ft.
e
Name
___ __
Stgnature Date Signature Date
3 0{ 4 � Pdge
!f the day af becoming an employee is from the first to the fifth day of the month, coverage is e�€ective
the tirst calendar day of ihe next month provided you are in active status and/or employed on that date.
if the day of becoming an employee is afiter the fifth caEendar day af the month, coverage is e�fective the
first day of the month after 31 days following the date of becoming an employee.
d
STEP 5 — EMf'LOY�R AGREEMENT
In maktng this appllcstion to 4Vyssta Insuronca Compaoy, Irx., a wholly�otvAed subsEdiary of Delta Denta) of Wisconsln, Inc, for group vislon coveroga unde� thls prog�am,
tha Gwup agreec and utxtarstands thts applicatian tivill 6ecome part of Iha Contratt executed by an auti+orfzed ofFlar of Wyssta. (t is �gr2ed 1?fat the <overage requasted
ls subject to the approval elN+y�il� and that no agent or represenlative has authoriry to make or madify tks appli<ation for covaage, Tha Graup hereby ceitifios Ifiat all of
tha above Informatlon Is tn.�s arrd correct. The Graup understand� thal eoverage vritl not be eNe<tive untif questlons regarding el�gibilEry (orcoverage have been aatisfacto�ily
resolred. Tha Group agrees to be 6ound by tha terms of Ihe Cantroctlssued by Wj�ssta, Misrepresentations that the Group makos (n Information or data �ubmilted to Wyssta
vr�lh this appliaatlon may affad Wyssta's obligalion to thefi jgup undet tha Contrad or cause 4Vyssta to resdnd tha Contrad. ,
Name
Sic�natur�r-
��rIC ��h1v
Approva! of coveragels tondngent upon Undenvrlt(rtg accsptance,
r��a
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ST�P 6 - 5UBM1T APPLfCATlO�I
?lease subrnit appiicatian with enroflment to �our Delta bental representative or n�aH ta:
Do(ta Dantal o} Wisconsin
AiM:157
280i Hoovor Rd„ PO Box 828
Stovons Point, Wf 54d81-0828
EmaiL �ales�deltad� vi. om
Fax: 7'15•343-7b23
<i�Elavision�ra�lpu�ap
12.2!? 12
F7U1•121'1
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