HomeMy WebLinkAboutWCA Group Health TrustWCA GROUP HEALTH TRUST
PARTICIPATION AGREEMENT
(2015 EDITION)
This Participation Agreement ("Agreement") is entered into and made effective as of
January 1", 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 for
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 ally 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.dependetits;
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)e "Employee" meanslan individual -participating 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 63 .897,
Wisconsin Statutes, or 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.
Particiption Agreetttent (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 patlicipate and participating in the Trust.
d) "Plan" or "Plans" means any employee health and welfare benefit plan or plans
(including any schedules, attaclunents, 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.
0 "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 extent 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.
Obligations of Member cued Employees. The Member and its Employees shall comply
fully with all provisions of this Agreement, the Pians and the Trust Agreement which
impose an obligation on the Mcihber or its Employees, as the case may be.
4. Obligations of the Trust. The Trust shrill comply fully with all provisions of this
Agreement, the Plans and the Trust Agreement which impose an obligation on the Trust.
S. Contributions by Afenther 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. Midinum•Paniclptrtlon Level. Il 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.
Participation Agreement (2015 Edition)
Page 3
c) Decline to offer the Plan to the Member if the Coverage Period has not yet begun.
Effective Date. This Participation Agreement shall be effective as of January 154, 2016
and shall continue in firll 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 1st shall remain in effect and shrill govern any
periods and claims occurring prior to January 1st.
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 ivlember fails to pay any premiums
or breaches any other obligation of this Agreement, the Plans or the Trust agreement.
10. Clahns Run-Ouf.
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
twelvemonths after the effective elate 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, whieliever is earlier.
11. Infos nrallon -Provided For- Bidcling P1117)oses.. The iVlember 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.
Pmticipation Agreement (2415 Edition)
Page 4
b) Pretniums 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.
e) 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 animal Coverage Period for which information is available,
subject to applicable state and federal laws governing medical confidentiality,
The Trust shall provide, for 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. Duty, to Cooperate. Member agrees to cooperate with the Trust including, without
limitation, agents 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 Agreenient, This Agreement, any Plans incorporated into this Agreement, the
Trust Agreement, any prior Pa►iicipation Agreement between the parties and any- Plans
incorporated therein constitute the entire agreement between the parties and supersede all
prior negotiations concerning the sonic subject.
14. Severability. 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 frilly severable, (b) this Agreement will be construed and enforced as if
such illegal, invalid, or unenforceable provision had never comprised a part hereof, (c)
the remaining provisions of this Agreement will retrain 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 such illegal, invalid, or unenforceable provision as may be possible,
15. Governing .Latin. This Agreement shall be governed by and construed in Accordance with
the laws of the State of Wisconsin.
['Remainder of this page left blank]
Pail icipation -Agreement (2015 Edition)
Page 5
IN 'WITNESS HERE, OF, 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
Signatu:-
NAME AUL l lDWl
Print or Type
TITLE , � V 410,40(
Print or Type
DATE I J r
'VCA GROUP HEALTH TRUST
Michael Lamont
Assistant Secretary, WCA GHT
DATE G1 tee' c 2e
Participation.Agreemeiit.(201 S .Edition)
Page 6
CITY Or OSHKOSH
(1101116-12131116)
Medical
Single 1 $ 755.00
Llmited'Family I $1,510.00
Family $1,888.00
WCA Group Health Trust will 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.
NOVEMBER 10, 2015 15-485 RESOLUTION
(CARRIED ___LOST LAID OVER WITHDRAWN 1
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 Avanuo
PA Lax 1 130
Qshkush,
5003,1130 City of Oshkosh
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 Wisconsin 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 savings by moving from their current partially self-funded 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 tirne, 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.
0 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 td $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 2016-2017 health, the 2016 dental and the 2016 vision insurance
agreement/applications.
Respectfully Submitted,
*�a-g IV
John M. Fitzpatrick
Assistant City Manager /
Director of Administrative Services
Attachments
cc:
Approved:
Mark A. Rohloff
City Manager
WCA Group Health Trust Participation Agreement
Delta Dental & Vision Group Applications
Pam Resch, HR Manager
2
Delta Dental of Wisconsin
Fully Insured - Croup Application
Delta Dental of Wisconsin Is vrabla to accept this document with any cheagos, cross•outs, whito•outs, ate., unless tho person signing
the application initials thoso changos.
In ordor to honor tho requested effective date of coverage, all_waxeriais, Frust be racoived by Delta Cental no later than five business
days pilor•lo the requested alfectivo date. Delta dental resorvos tho tight to designate the effective data if matedalo ere not
rocolvad wlihfn this timeframe. Please print clearly.
REOVIREMPNTS TO ENROLL A NEW EMPLOYER
❑ A completed employer appllcatIon form
❑ A check for the first month's premium, and o completed ACH form (ifACH is solectod)
Q A copy of tha sold proposal ouillrling benefits
Il Completed enrollment forms (Enrollment forms may not be required if ol.191biliq reporting molhod is spreadsheet or elearortle)
STEP I — EMPLOYER INFORMATION
City of oshkash
Legal Burinoss Nomo
INFORMATION IN THIS BOX IS REQUIRW
Total blur tbarof KlI{� lble Employees; 660
(Include completadrvahars forlhose Flet onroillniri
Total Number of Employeas Enrolling: T1313
Roquestod Effective Date; January 1. '2016
BA ill Wle—toAQ
215 Church Avenue, Room 401
AA dlos-s
PD Box
Oshkosh
SY1 5,1903-1130
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920.236.5111
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Payn►ont Molhad: ❑AC11 f5ao page 3) +M Check M check from tho group for Iho first month's premlum Is requirad forhoihpaynient mothods)
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~ I of ,$ I Peon
STEP 2 - PLAN DESIGN
Imporlanl; This sacilon must be complated by lho tz rtt�t fhesmplQyCriL
All Information must be p(ovided. Please print clearly.
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Coverage for domestic Naitnors:
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STEP 3 - AGENT INFORMATION
J11n Slane Associale(1 Atiancinl Grotto 91-2189930
Agent flamo - Agency Name Agency Fad. 10 No.
711 ElmiitoWer Drive. Kimberly'M 54136 11111.Sin RO RAAassocllttetdit3aticlnll;rollmol31
Addross Fmoll
07.0-731.0100 WI License #963156
£'hong SoclolSocvilty No, ijqppl Etkonso No. [jadldatl ,Fs illtatod ttlatkatplact UserfD
It commisllon Is to be paid to someone other than the above,ploalo slate:
Not Allnidc bla - Nei of Colmnissinits
Nanta
Consultant's Name phono
Address—.. -4Y
Email
STEP 4 -AC:H FINANCING AGREEMENT (OPTIONAL)
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rrtonIWsprlfnlonlIs rogvirodvvflh the appllcaLim nandlhis ACH lam,
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STEP a -- EMPLOYER AGREEMENT
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Delta dental of WIsconsh
Delta lislod— Croup Application
Wssta Insurance Company, a whollyovinod subsidiary of Dolts pontal of Wisconsin, Is unable to accept this documont with any
ngos, crass•outs, vrhite�ouls, otc, la the answers givon un{cis the person sloning the application Initials all such changes.
In orclor to hoaioriitoroquosted offactivedata of covorasgo, all materials must be recolvod byW'ysito no letor than (w buslness days
prfor to the roqueslod-offoolvo data, Wyssta reserves tho right to do4lonoto tho offodlvo rOat& If materials aro not received within
this tlnmleante, ploase punt clearly,
R15QUIREMENTS TO ENROLL GROUP
[] This completed group application form
❑ A chock for the Rrst month's pronilum, end if AC1112 chosen, a completed ACH farm -details on page I
(subsequont p(omlum payment)
❑ A copy of tha sold proposal outihihig boriofits
❑ Cornplo(od onrolirnortt forms
(►inrollmonf {orals mavaot be roqulredf!eligibility reporting methodfs spreadsheet oralachonle)
$T1 P 1- GROUP INFORMATION — -- ----
Tole! number of eifglbfo employees: 600
(include completed ivalvers lot chore nht enrolling)
City of Oshkosh Total number of'employeosonrolliog: TBD -
1a��1
Roquosted effective data: January 1, 2016
?.16 Church Avenue, Room 401
Address— PO aox PO 60xxrp
Oshkosh W1 64903-1130 -
ciiy slato [p
920.236.6111
nusfnoss phone Fax
City Government 9121.04
Notwo of hutfnoss S(C code
Prim Reseh Human Resources hlen000r llre6ch0_C1,oshkosh.wWs
frena it Contact nlnte — - - Til 0 Emall _.
b the bomAt conlad authoilsed to lion dia PI11(Protocted lloaith lnlormatlon)? Ca Yes Q Nv
Kim Kaulza Beneflte Coordinator kkautxa c@cl,oshkosh,w1,tie
Who contact name ^� 710e Finall
Is file billfaq contact cethori:ed to -handle PHI (Protected Health lnformatlon)l - d Yos 0 N
8111fng dellvery method: 0 L'm,ll (spoclry) kkaulza c7ol,oshkosh.w1,us 0 Popor Q Fax
No previous carrier
PfeVleUs vlrlon carrier litoppllcable.)
I of -11 Pogo
STEP 2 -- PLAN DESIGN Fogvostlonsonthlsapplfcallors,
contact your agsnt orcal! our Sales
Important: chis soctlon must be comploted by the a�y2G doparimon t at 800.236.3713 or
All Information must be provided. Ploeso print (loar y, email Sa n&�tl9ftaerttalt/LsQrst
• 1 r t r
I •
Networkr ® Access Select Renefsl Plan Typo, ®A Q t'1
Chooso Ono plan, than fill in banelftss
Comprehensive Plan (Pleats velar to your prOpara! to 011 fnplan benefits)
Allowance 460 /.140 (Frames/Contact Lomas)
COpay 20 / 2� (E;[ams/SlandardPlastic tenses)
rroquonq12/ 12 /—t2 (Exams/LensosorConlacllonsos/Frames)
El
ldalerlels•OnlyPian hJlovianaa (Please ro/or to yew proposal to chant plan allmvance)
5150
$4C0
$250
[a Nwistanclud Plan (Pleato ra/er to yourproposal to M114 plop bon -01s)
Allowonco.,.,,_._. /,____. (rraMas/ COntdd lansos)
Copay /' __ (rxanss/SlandardPlasllctanses)
Frequency T , / _ / (Sxoms/terssesorContact tansos/Frames)
4�7Fi`3 t F4�" I[ V "' hS�11 1� s� k}1§LZa2 S��V u t1 44Z«� `
p 4,i:r,:eS i7 S•i " r; F{t .,1 iti fu i
�4{k�!•'l , #°`'`'•�ila''e).. ?f5,r¢t��.r,§"sLa
MIN-
jr. , x1r, °.G % 0 % 0 % 0 %
7�tr�`�1 - � Emp.fTAaalAtur
„•{ Fnp:r/n Frn�! Ea'P!d/ra Fr[p/Orrrr�'rnl U[/rrlrnH
�• $e1e4F ;i•,t'' 3£ $ 1t)r68
lvfo•lter, ',:.' . ��c'�',a,.�It§ $ S $ 5,35 $10.57
.S I.e;1;;r`,�+E Frap.rT.�autdtr§
thrle•Ifef, •! ti)f•��;�;•j•ih' ., Enp!a/u Fartr Fnplryrr CYp.IDIPhd:nl Urpr,rlrnU
of ldU/•Ilei :�
.s
2,Pill In r :�'tinl N 11 :l` :'ti"• • [triti Li r�1 h [ §� '[}-i' S Fi3x_ w/
;EP 5''��l � 'a4 � ��`i"I�:jt✓� � � <��' � l' o, r• �er 5••��. la•.,:1'}; kc:'t}' � ti�zs�r ,t � +,��X� }}� 5(##
cont(lbulloA i;
ontployor 'r s;°� • t� 3x. §�.�:.:'s)„r�. C$ C7;�..� .X.o ;s•.` r}fvAi,:'�;..r.'iti �F51i ��v�c§J��:. , ?tr.;'I
polcontagos ' ¢i 1�i °� % %
3. Fill In rates 5§t ..5 [np17/rr FMp./spt4lf FMp./CAId/[n} Fnp,/Spvur/C1Tk¢rn)
?,ii>?:F'+§4 ti fmployrr FTp./Spcusr Eup./CAllqu) trap./Spool)/C1ilirrA
2 of -11 isaurr
1 A , R
6niployoes Oro e1191blo lot tovorega on (141041 ono): Tormlmilon data lot ompioyoa►I
Date of hire (no svblting p4rlod) [] bolo al terndnaslon �] End of monlhlollovring termfnatlon
1st of the month lolloMng the data of hlre W Othor (spo<lly)
rrffiioieni•" n��" days aftor data of hire
Gopendanls/students era covered tot
sys 4mpt y tent oftor data of hfro E] Olohdato FO End of nteeth follewIng blrthdsle
Employoo totals of 41101bllltyl
Coverago for dorneslic peftnors:
Q al) hours minlnivm ovwatto hours warhod per weak Yos t�J �
/� [� No
�l Othor(spooYy) POO VS Dal-W,4,r,
..................................... .............. ......................................
._
STEL' 3 -AGENT INFORMAT)ON
Jan Slage Assoclaled Modal Group 01.2109030
Aoent name Agoncyname � UN.
711 ElearthovwerDriye, Kimberly, Wl 84936 lana.hltnerar?asseclalvdllnanclalgroup.sem
Address small
020.731.0400 _ Wf License 11_908956
Phone ticanso No. Social saeurhy No,
JI comollsston is to be paid to someono other than the above, please state:
Not Appficablo - Not of Commissions
Marna
Coniullont's name
Address Small
STEL' 4--ACH FINANCING AGREEMENT
Now For "I'll
rnruredpfsnswllhhtH, a <ho<`t far thv first month's premlam is raqufr4dwgh she apple<atlon and tills ACH farm,Avlaa+asad<toulnphousa
((ACA) transfer or fvndsts s ++fey ouyy, and olfocltya yray w onwic praf:er fuadlnq of the Qroup's account, 7o sot up an ACH trrnslar, plvaso <omploto Iho
fn tmetfonbelow,7hliIANrmaVan17onlyfaqu}red [oryraupspayingUfaACH,
Can Welnorno Contact phone
Contact omalf socon6afycoeilaot emall
Depository namo Doposilory IransllIVIDA No.
A<COVAt namo Account No.ayings or Chocking
IJ*4 harol+yauthotIIe 40a DonfA of WhConIIn, Inv., horatni(lar called Cornpon/ to tnitlite era>?It anfrte s ind to tnithte, tf aacats aiy, <r4dit ontrros and
ad)vswionts for any dahlt onlrlsi In array co my(our) accovAl and lho flaandalrn Ulcus ladlcatod boyo, h4nln uiled04PosftasA to 444114 nd/arSradit I h a Lama
such 1e<auni. Uls oulhodlyls lorsmaln In full ror<a ind offott JAPE Cars�� any ha I recalysd wrltwn noslflcallon from rAa for aIther of us1 of Its tonWntllon In such
Ilnsa 36d In such fnsnnay 4a to afford Cam parry and fropasltosy a r 1;o11 Sia oppollualty to act on h,
Name Name
Signature Date Sfgrtaluro 0019
3 of 4 I Newo
If the clay of becoming an employee Is from the first to the fifth day of the month, coverage Is effective
the first calendar day of the next month provided you are in active status and/or employed on that date,
if the day of becoming 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 (late of becoming an employee,
r
STEP 6 -- EMPLOYER AGREEMENT
In mtYing IRh appll(aUan {o Yllsth lnturanea Camperr� Inc., a vshaYyatve+d (ubt!d!ar/ of DdW Cant+l atl'Iireanrin, Irro for gaaupp H1:en iaYe++gga anter llfs program,
she flraup tyraar trd en�i+rilt;sdt thh apppfxal(ah evil h+[alrt4 plrl of lha Coelra(( 4x«Vlad by to tuofurtiid oll!SE+ of Yj�xtta. ll (t tgrE+d Inst Ehe <avt+rgg+ earµ�asted
IF sa1l+(i lo(ho appprayslo1Wyah (nd t 3 to agent or raprasl+ittl+a ttfe s'Away0 ,kaor madlfyth!, tpp c001A ertaY(rt a, iha9raap lser+bycEIVRrs lht( ayof
(ha t6ava fnlaurutlan It w4 and Garratt.lh►tlravp vnderttandr 0++t ear+rrgssrlInot W affool to until �ua(ltens eeg�rdrt el!glbflity fareawraae l+�rp M Ep sESlifr(tar'tJ
mroty+d. The Owuptpea::lobabaunrlh�(F.atermsoftheCantretlf,rvadSyyY,yss(a.htlnepr61NA4(lanrClho[lr��p.rka3InInfornu(lanerdatarulrnttledt*y1j lta
s+iUt ills appYtttlan msy allad 1"Iyislt t a61 q;Ron to l>tajr�apundrr the Canlraat oe uuu 1iy}sta to rudnd lh+ Cantttsl.
SfprtJlU� Ww /( 8ohlol't'
Approval of covaraoall contingoat uponUadarwrltfn0 accepla,
STEP 6 - SUBMIT APPLICATION
Mom submit applltallon vAllt enrollment to your Delta Dental rcprasontallvo OF mall toe
Nita Dontal of SVlsconstn
AM-, IST
2801 HooYor Rd,, p0 OVA 828
Stavons Polnb µR 84d81•Q828
Icmall:�alas.�si2lt�su(ltaldscnt
pais 71S•3-13.7623
elullavlslono I nap( qpp
12.2012
F701.1212
4 of rl I pale
Il