HomeMy WebLinkAbout20072176.tiff Great-West®
• HEALTHCARE
December 6, 2006
Weld County Government
915 10th Street
PO Box 758
Greeley, CO 80632
Dear Jewel Vaughn:
We would like to take this opportunity to once again thank you for your business. Great-West Life &Annuity
Insurance Company prides itself on providing excellent service to our customers.
Enclosed are amendment/replacement contract(s)for your plan. We would appreciate your prompt review of
these documents. If you agree and accept the amendment/replacement contract(s), no further action is
necessary on your part. If you disapprove, then you must contact us in writing within 60 days of the date of this
letter with your request for changes or alterations. If you have not communicated to us in writing within the above
time frame, it will constitute your acceptance of the amendment as submitted.
Should you have any questions or concerns, or would like to discuss your account, please contact your plan
• services representative.
Sincerely,
Diane Haas
Great-West Healthcare
cc: Reed Smith, Group Representative— Denver Group Sales Office
• Great-West Healthcare refers to products and services provided by Great-West Life 8 Annuity Insurance Company and its subsidiaries(Alfa Health&Life
Insurance Company and Great-West Healthcare HMOrHCSC companies).It also refers to the group business that is underwritten by New England Life Insurance
Company and Metropolitan Life Insurance Company which is currently administered by Great-West Life&Annuity Insurance Company.Great-West Life&Annuity
Insurance Company is not licensed to do business in New York.Products are sold in New York by its subsidiary First Great-West Life&Annuity Insurance
Company,White Plains,N.Y.
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ARTICLE - SCHEDULE OF EXCESS LOSS INSURANCE
This Schedule is applicable only to the Excess Loss Insurance Policy issued to the Policyholder.
Each category, coverage basis, and optional feature of Excess Loss Insurance described herein and in each of
any attached Riders (hereafter, collectively referred to as "Categorized Coverage") applies to the Policyholder
only when the appropriate selection of such Categorized Coverage is indicated by the Company in the
appropriate space provided.
A. POLICYHOLDER'S AND PLAN'S INFORMATION, POLICY'S IMPORTANT DATES AND COVERAGE
PERIODS
1. List of Plans Included for Excess Loss Insurance Coverage under this Policy:
Medical, Outpatient Prescription Drugs
2. Policy's Important Dates & Renewal Term:
The Effective Date of this Policy: January 1, 2005
The Effective Date of this Amendment January 1, 2007
The Expiration Date of this Policy: End of 1-year term, subject to renewal
The Anniversary Date of this Policy: Each January 1 beginning in 2006
Expense Incurral Period:
Specific: The Policy Year(s)
Aggregate: The Policy Year(s)
• Expense Payment Period:
(a) While the Policy is in effect:
Specific: The Policy Year
Aggregate: The Policy Year
(b) After the Policy ends for any reason except the Policyholder's insolvency or failure to pay premium on
time:
Aggregate: The Final Active Policy Year plus 15 months after the Policy ends.
B. COVERED PERSONS
Excess Loss Insurance is limited to Covered Benefits incurred by persons covered under Your plan:
Specific Excess Loss Insurance:
All persons who are validly covered pursuant to Plan's provisions.
Aggregate Excess Loss Insurance:
All persons who are validly covered pursuant to Plan's provisions.
C. SPECIFIC EXCESS LOSS INSURANCE
You are insured for the Specific Excess Loss Insurance.
1. Company's Limits of Liability:
Overall Maximum Specific Reimbursement that the Company will be liable to reimburse You per Covered
Person during such person's lifetime is: Unlimited
2. Specific Deductible Amount:
• $150,000.00 in Covered Benefits incurred by the same Covered Person (Individual Deductible)
3. Covered Benefits:
Medical
1
D. AGGREGATE EXCESS LOSS INSURANCE
You are insured for the Aggregate Excess Loss Insurance.
• Monthly Attachment Points will be provided to you in writing.
1. Covered Benefits:
Medical, Outpatient Prescription Drugs
2. Minimum Monthly Attachment Limit: is determined as described under Article II - Definitions by using
the specified percentage of 90%.
RIDER#D.1.2: Monthly Accommodation, Deficit Carryforward Type A.2 & Terminal Protection.
Applicable data and points:
- Number of consecutive calendar months included as Policy Months after the Policy ends: 15 months.
- Minimum Terminal Attachment Limit: is determined as described under Article—Definitions by using
the specified percentage of 90%.
Terminal Attachment Points will be provided to you in writing.
E. PREMIUMS
Monthly premium for each Categorized Coverage is determined for the premium unit method by multiplying
the applicable premium rate (expressed as a dollar amount) by the applicable number of the specified
premium units covered under the Plan on the first day of each Policy Month.
Premium at Termination: At the end of this Policy there is a requirement for payment of a monthly premium
for Terminal Protection. The premium is calculated by multiplying the applicable premium rate by the
applicable number of the specified premium units on the first day of the last Policy Month preceding the
terminate date of this Policy. The premium will be for the first one Policy Month(s)following termination and
• will be payable in the first month following the termination date of the Policy.
If more than one type of premium unit is utilized, add all products of the multiplications for all identified types
of the premium unit together to arrive at the total monthly premium for such Categorized Coverage.
F. NAME OF THIRD PARTY PLAN ADMINISTRATOR (TPA)
Great-West Life &Annuity Insurance Company
G. BANKING OPTIONS (identifies the frequency of your withdrawals from Your Bank Account for premiums
and payment for Claims):
Claims: Weekly
Premium and Administration Fees: Monthly
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•
2
AGREEMENT INSTRUCTIONS
FOR GUARANTY ASSOCIATION NOTICES
•
AND OTHER STATE REQUIRED NOTICES
The enclosed State Guaranty Association Notices are considered to be a part of the employee booklet. These
Notices describe the protection a resident receives through the Association. Under state law, a copy of the Notice
must be given to each employee who elects coverage under this Plan and resides in a state for which a Notice
has been provided.
General Instructions for State Notices -Agreements:
• State Notices must be provided to all employees enrolling in your Plan — based on the employee's state
of residence.
• Please review the documents attached to this sheet and provide copies to enrolling employees
according to the state in which he/she resides.
•A Notice is required if the Contractholder is sitused in that state or has residents of that state.
•
•
1
CALIFORNIA GUARANTEE ASSOCIATION ACT -SUMMARY
CALIFORNIA LIFE AND HEALTH INSURANCE GUARANTEE ASSOCIATION ACT SUMMARY DOCUMENT
• AND DISCLAIMER
Residents of California who purchase life and health insurance and annuities should know that the Insurance
companies licensed in this state to write this type of insurance are members of the California Life and Health
Insurance Guarantee Association (CLHIGA). The purpose of this Association is to assure that Policyholders will
be protected, within limits, in the unlikely event that a member insurer becomes financially unable to meet its
obligations. If this should happen, the Guarantee Association will assess its other member insurance companies
for the money to pay the claims of insured persons who live in this state and, in some cases, to keep coverage in
force. The valuable extra protection provided through the Association is not unlimited, as noted below, and is not
a substitute for consumers'care in selecting insurers.
The California Life and Health Insurance Guarantee Association may not provide coverage for this Policy. If
coverage is provided, it may be subject to substantial limitations or exclusions, and require continued residency in
California. You should not rely on coverage by the California Health Insurance Guarantee Association in selecting
an insurance company or in selecting an insurance Policy.
Coverage is NOT provided for your Policy or any portion of it that is not guaranteed by the insurer or for which you
have assumed the risk, such as a variable Contract sold by prospectus.
Insurance companies or their agents are required by law to give or send you this notice. However, insurance
companies and their agents are prohibited by law from using the existence of the Guarantee Association to
induce you to purchase any kind of insurance Policy.
Policyholders with additional questions should first contact their insurer or agent, and may then contact:
Executive Director
California Life and Health Insurance Guarantee Association
• .P. O.. Box 16860
Beverly Hills, CA 90209-3319
(323) 782-0182
Consumer Service Division
California Department of Insurance
300 South Spring Street
Los Angeles, CA 90013
(800) 927-4357 or(213) 897-8921
Below is a brief summary of this law's coverages, exclusions and limits. This summary does not cover all
provisions of the law; nor does it in any way change anyone's rights or obligations under the Act or the right or
obligations of the Association.
COVERAGE
Generally, individuals will be protected by the California Life and Health Insurance Guarantee Association if they
live in this state and hold a life or health insurance Contract, or an annuity, or if they are insured under a group
insurance Contract, issued by a member insurer. The beneficiaries, payees or assignees of insured persons are
protected as well, even if they live in another state.
EXCLUSIONS FROM COVERAGE
• However, persons holding such Policies are not protected by this Guarantee Association if:
• Their insurer was not authorized to do business in this state when it issued the Policy or Contract.
2
• Their Policy was issued by a health care service plan (HMO, Blue Cross, Blue Shield), a charitable
organization, a fraternal benefit society, a mandatory state pooling plan, a mutual assessment
company, an insurance exchange, or a grants and annuities society.
. • They are eligible for protection under the laws of another state. This may occur when the insolvent
insurer was incorporated in another state whose guarantee association protects insureds who live
outside that state.
The Guarantee Association also does not provide coverage for:
• Unallocated annuity Contracts; that is, Contracts which are not issued to and owned by an
individual and which guarantee rights to group Contract holders, not individuals.
• Employer and association plans, to the extent they are self-funded or uninsured.
• Synthetic guaranteed interest Contracts.
• Any Policy or portion of a Policy which is not guaranteed by the insurer or for which the individual
has assumed the risk, such as a variable Contract sold by prospectus.
• Any Policy of reinsurance unless an assumption certificate was issued.
• Interest rate yields that exceed an average rate.
• Any portion of a Contract that provides dividends or experience rating credits.
LIMITS ON AMOUNTS OF COVERAGE
The Act limits the Association to pay benefits as follows:
• for Life and Annuity Benefits:
- 80% of what the life insurance company would owe under a life Policy or annuity Contract up to:
- $100,000 in cash surrender values;
- $100,000 in present value of annuities; or
- $250,000 in life insurance death benefits.
• - A maximum of$250,000 for any one insured life no matter how many Policies and Contracts there
were with the same company, even if the Policies provided different types of coverages.
- for Health Benefits, a maximum of$200,000 of the contractual obligations that the health insurance
company would owe were it not insolvent. The maximum may increase or decrease annually based
upon changes in the health care cost component of the consumer price index.
PREMIUM SURCHARGE
Member insurers are required to recoup assessments paid to the Association by way of a surcharge on premiums
charged for insurance Policies to which the Act applies.
•
3
COLORADO PROTECTION ASSOCIATION ACT
SUMMARY OF THE COLORADO LIFE AND HEALTH INSURANCE
PROTECTION ASSOCIATION ACT AND
NOTICE CONCERNING COVERAGE LIMITATIONS
AND EXCLUSIONS
INTRODUCTION
Residents of Colorado who purchase life insurance, annuities or health insurance should know that the insurance
companies licensed in this state to write these types of insurance are members of the Life and Health Insurance
Protection Association. The purpose of this Association is to assure that Policyholders will be protected, within
limits, in the unlikely event that a member insurer becomes financially unable to meet its obligations. If this should
happen, the Association will assess its other member insurance companies for the money to pay the claims of
insured persons who live in Colorado and, in some cases, to keep coverage in force. The valuable extra
protection provided by these insurers through the Association is limited, however. And, as noted below, this
protection is not a substitute for consumers' care in selecting companies that are well-managed and financially
stable.
IMPORTANT DISCLAIMER
The Life and Health Insurance Protection Association may not provide coverage for this Policy. If
coverage is provided, it may be subject to substantial limitations or exclusions, and require residency in
Colorado. You should not rely on coverage by the Life and Health Protection Association in selecting an
insurance company or in selecting an insurance Policy.
Coverage is NOT provided for a Policy or any portion of it that is not guaranteed by the insurer or for which you
• have assumed the risk.
Insurance companies or their agents are required by law to give or send you this notice. However, insurance
companies or their agents are prohibited by law from using the existence of the Association to induce you to
purchase any kind of insurance Policy.
SUMMARY
The state law that provides for this safety-net coverage is called the Life and Health Insurance Protection
Association Act. Below is a brief summary of this law's coverages, exclusions and limits. This summary does not
cover all provisions of the law; nor does it in any way change anyone's rights or obligations under the act or the
rights or obligations of the Association.
COVERAGE
Generally, individuals will be protected by the Life and Health Insurance Protection Association if they live in this
state and hold a life or health insurance Contract, or an annuity, or if they hold certificates under a group life or
health insurance Contract or annuity, issued by a member insurer. The beneficiaries, payees or assignees of
insured persons are protected as well, even if they live in another state.
This Information is Provided By:
Life and Health Insurance Colorado Division of Insurance
Protection Association 1560 Broadway, Suite 850
• P.O. Box 480025 Denver, Colorado 80202
Denver, Colorado 80248-0025 (303) 894-7499
(303) 292-5022
4
EXCLUSIONS FROM COVERAGE
• Persons holding such Policies or Contracts are notprotected by this Association if:
• they are not residents of the State of Colorado, except under certain very specific circumstances;
• the insurer was not authorized or licensed to do business in Colorado at the time the Policy or Contract
was issued;
• their Policy was issued by a nonprofit hospital or medical service organization (e.g., the"Blues"), an
HMO, a fraternal benefit society, a mandatory state pooling plan, a mutual assessment company or
similar plan in which the Policyholder is subject to future assessments, or by an insurance exchange.
The Association also does not provide coverage for:
• any Policy or portion of a Policy which is not guaranteed by the insurer or for which the individual has
assumed the risk;
• any Policy of reinsurance (unless an assumption certificate was issued);
• plans of employers, associations or similar entities to the extent they are self-funded or uninsured
(that is, not insured by an insurance company, even if an insurance company administers them);
• interest rate yields that exceed an average rate;
• dividends;
• experience rating credits;
• credits given in connection with the administration of a Policy or Contract;
• annuity Contracts or group annuity certificates not owned by an individual unless and to the extent
guaranteed to an individual by the insurer;
• annuity Contracts or group annuity certificates used by nonprofit insurance companies to provide
retirement benefits for nonprofit educational institutions and their employees;
• Policies, Contracts, certificates or subscriber agreements issued by a prepaid dental care plan;
• sickness and accident insurance when written by a property and casualty insurer as part of an
automobile insurance Contract;
• unallocated annuity Contracts issued to an employee benefit plan protected under the federal
• Pension Benefit Guaranty Corporation;
• Policies or Contracts issued by an insurer which was insolvent or unable to fulfill its contractual
obligations as of July 1, 1991;
• Policies or Contracts covering persons who are not citizens or permanent residents of the United
States;
• financial guarantees, funding agreements or guaranteed investment Contracts not containing
mortality guarantees and not issued to or in connection with a specific employee benefit plan or
governmental lottery;
• any kind of insurance or annuity, the benefits of which are exclusively payable or determined by
a separate account required by the terms of such insurance Policy or annuity maintained by the
insurer or by a separate entity.
LIMITS ON AMOUNT OF COVERAGE
The act also limits the amount the Association is obligated to pay out. The Association cannot pay more than
what the insurance company would owe under a Policy or Contract. Also, for any one insured life, the Association
will pay a maximum of$300,000 - no matter how many Policies and Contracts there were with the same
company, even if they provided different types of coverages. Within this overall $300,000 limit, the Association
will not pay more than $100,000 in cash surrender values, $100,000 in health insurance benefits, $100,000 in
present value of annuity benefits, or$300,000 in life insurance death benefits - again, no matter how many
Policies and Contracts there were with the same company, and no matter how many different types of coverages.
FORM:RA3441
•
5
WYOMING GUARANTY ASSOCIATION ACT
• NOTICE CONCERNING COVERAGE LIMITATIONS AND EXCLUSIONS UNDER THE WYOMING LIFE AND
HEALTH INSURANCE GUARANTY ASSOCIATION ACT
Residents of Wyoming who purchase life insurance, annuities or health insurance should know that the insurance
companies licensed in this state to write these types of insurance are members of the Wyoming Life and Health
Insurance Guaranty Association. The purpose of this association is to assure that Policyholders will be protected,
within limits, in the unlikely event that a member insurer becomes financially unable to meet its obligations. If this
should happen, the Guaranty Association will assess its other member insurance companies for the money to pay
the claims of insured persons who live in this state and, in some cases, to keep coverage in force. The valuable
extra protection provided by these insurers through the Guaranty Association is not unlimited, however. And, as
noted below, this protection is not a substitute for consumers'care in selecting companies that are well-managed
and financially stable.
The Wyoming Life and Health Insurance Guaranty Association may not provide coverage for this Policy. If
coverage is provided, it may be subject to substantial limitations or exclusions, and require continued residency in
Wyoming. You should not rely on coverage by the Wyoming Life and Health Insurance Guaranty Association in
selecting an insurance company or in selecting an insurance Policy.
Coverage is NOT provided for your Policy or any portion of it that is not guaranteed by the insurer or for which you
have assumed the risk, such as a variable Contract sold by prospectus.
Insurance companies or their agents are required by law to give or send you this notice. However, insurance
companies and their agents are prohibited by law from using the existence of the guaranty association to induce
you to purchase any kind of insurance Policy.
• The Wyoming Life and Health Insurance Guaranty Association
PO BOX 480164
Denver, Colorado 80248
State of Wyoming Department of Insurance
Herschler Building
122 West 25th Street
Cheyenne, Wyoming 82002-0440
The state law that provides for this safety-net coverage is called the Wyoming Life and Health Insurance Guaranty
Association Act. Below is a brief summary of this law's coverages, exclusions and limits. This summary does not
cover all provisions of the law, nor does it in any way change anyone's rights or obligations under the act or the
rights or obligations of the guaranty association.
COVERAGE
Generally, individuals will be protected by the Wyoming Life and Health Insurance Guaranty Association if they
live in this state and hold a life or health insurance Contract, or an annuity, or if they are insured under a group
insurance Contract, issued by a member insurer. The beneficiaries, payees or assignees of insured persons are
protected as well, even if they live in another state.
EXCLUSIONS FROM COVERAGE
However, persons holding such Policies are not protected by this Association if:
• they are eligible for protection under the laws of another state (this may occur when the insolvent insurer was
• incorporated in another state whose guaranty association protects insureds who live outside that state);
• the insurer was not authorized to do business in this state;
6
• their Policy was issued by a fraternal benefit society, a mandatory state pooling plan, a stipulated premium
insurance company, local mutual burial association, a mutual assessment company, or similar plan in which
the Policyholder is subject to future assessments, or by an insurance exchange.
•
The Association also does not provide coverage for:
• any Policy or portion of a Policy which is not guaranteed by the insurer or for which the individual has
assumed the risk, such as a variable Contract sold by prospectus;
• any Policy of reinsurance (unless an assumption certificate was issued);
• interest rate yields that exceed an average rate;
• dividends;
• credits given in connection with the administration of a Policy by a group Contractholder;
• annuity Contracts issued by a nonprofit insurance company exclusively for the benefit of nonprofit educational
institutions;
• unallocated annuity Contracts (which given rights to group Contractholders, not individuals).
• any plan or program of an employer or association that provides life, health or annuity benefits to its
employees or members to the extent the plan is self-funded or uninsured.
LIMITS ON AMOUNT OF COVERAGE
The act also limits the amount the Association is obligated to pay out: the Association cannot pay more than what
the insurance company would owe under a Policy or Contract. Also, for any one insured life, the Association will
pay a maximum of$300,000 - no matter how many Policies and Contracts there were with the same company,
even if they provided different types of coverages. Within this overall $300,000 limit, the Association will not pay
more than $100,000 in cash surrender values, $100,000 in health insurance benefits, $100,000 in present value
of annuities, or$300,000 in life insurance death benefits - again, no matter how many Policies and Contracts
there were with the same company, and no matter how many different types of coverages.
•
•
7
GREAT-WEST LIFE &ANNUITY INSURANCE COMPANY
Executive Offices—Greenwood Village, Colorado
(Company)
•
Excess Loss Insurance Policy
issued to
Weld County Government
(Policyholder)
The above Excess Loss Policy No. 0258610 is amended as follows:
SPECIFIC EXCESS LOSS LEVEL
The previously issued Policy section entitled ARTICLE—SCHEDULE OF EXCESS LOSS INSURANCE is hereby
deleted and replaced by the attached Policy section entitled ARTICLE—SCHEDULE OF EXCESS LOSS
INSURANCE, to reflect the change to the section entitled Specific Excess Loss Insurance.
MINIMUM MONTHLY ATTACHMENT LIMIT AND MINIMUM TERMINAL ATTACHMENT LIMIT
The previously issued Policy sections entitled ARTICLE—SCHEDULE OF EXCESS LOSS INSURANCE is hereby
deleted and replaced in its entirety by the attached Policy section entitled ARTICLE—SCHEDULE OF EXCESS
LOSS INSURANCE, to reflect the change to the section entitled Aggregate Excess Loss Insurance. The
Aggregate Excess Loss Insurance section has been revised to include a Minimum Monthly Attachment Limit and
Minimum Terminal Attachment Limit.
Article II entitled DEFINITIONS is revised as follows:
(1) The term Cumulative Attachment Limit in the Policy is hereby deleted and replaced by the following
• defined term; and
(2) The terms Minimum Monthly Attachment Limit and Minimum Terminal Attachment Limit are hereby added
to the Policy.
CUMULATIVE ATTACHMENT LIMIT
(1) During the Policy Year while the Policy remains in effect, for each Policy Month, means the greater
amount of:
(a) The sum of the Monthly Attachment Limit for the current Policy Month plus the Monthly
Attachment Limit for each of the previous Policy Months in the then current Policy Year; or
(b) The sum of the Minimum Monthly Attachment Limit for the current Policy Month plus the Minimum
Monthly Attachment Limit for each of the previous Policy Months in the then current Policy Year.
(2) After the Policy ends for any reason except the Policyholder's insolvency or failure to pay premium on
time, means:
(a) For the first Policy Month after the Policy ends, the sum of the Terminal Attachment Limit or the
Minimum Terminal Attachment Limit for such policy month, whichever amount is greater, plus the
Cumulative Attachment Limit for the last Policy Month prior to the end of this Policy.
(b) For the second and each subsequent Policy months after the Policy ends, the sum of the
Terminal Attachment Limit or the Minimum Terminal Attachment Limit for such Policy Month,
whichever amount is greater, plus the Cumulative Attachment Limit for the prior Policy Month.
MINIMUM MONTHLY ATTACHMENT LIMIT
. (1) For each Policy Month during the first Policy Year that this Policy is in effect, is the amount equal to the
specified percentage (as shown in the Schedule)of the Monthly Attachment Limit for the first Policy
Month of the first Policy Year.
(2) For each Policy Month during the second or a subsequent Policy Year that this Policy is in effect, is the
amount equal to the specified percentage (as shown in the Schedule) of the product of the appropriate
• Monthly Attachment Point (as shown in the Schedule)for the then current Policy Year multiplied by the
appropriate number of the Attachment Units on the first day of the Policy Month which is two month[s]
prior to the last Policy Month of the immediately prior Policy Year.
If more than one type of the Attachment Unit is utilized as stated in the Schedule, add all products of the
multiplications pursuant to the above paragraph for all identified types of the Attachment Unit together, then
multiply such sum by the specified percentage as indicated above to produce the total amount of the
Minimum Monthly Attachment Limit for each such Policy Month.
MINIMUM TERMINAL ATTACHMENT LIMIT
is to be calculated monthly after the Policy ends as follows:
(1) If the Policy ends on any date during its first Policy Year or is non-renewed after the end of its first
Policy Year:
(a) For each of the first two Policy Months after this Policy ends, is the amount equal to the specified
percentage (as shown on the Schedule) of the product of the appropriate Terminal Attachment
Point (as shown in the Schedule) multiplied by the appropriate number of the Attachment Units
on the first day of the first Policy Month.
(b) For the third and each subsequent Policy Months after this Policy ends, the Minimum Terminal
Attachment Limit for such Policy Month is zero.
(2) If the Policy ends on any date during or after its second or subsequent Policy Year:
(a) For each of the first two Policy Months after this Policy ends, is the amount equal to the specified
• percentage (as shown on the Schedule) of the product of the appropriate Terminal Attachment
Point (as shown in the Schedule) multiplied by the appropriate number of the Attachment Units
on the first day of the first Policy Month which is two month(s) prior to the last Policy Month of the
immediately prior Policy Year.
(b) For the third and each subsequent Policy Months after this Policy ends, the Minimum Terminal
Attachment Limit for such Policy Month is zero.
If more than one type of the Attachment Unit is utilized as stated in the Schedule, add all products of the
multiplications pursuant to the above paragraphs for all identified types of the Attachment Unit together, then
multiply such sum by the specified percentage as indicated above to produce the total amount of the
Minumum Terminal Attachment Limit for each such Policy Month.
Article entitled PREMIUM PROVISIONS is amended to delete reference to the Company's right to change
premium rates, factors, Monthly Attachment Limit calculation, points and Specific Deductible Amount(s) on the
first day of the month following a change in the number of Covered Persons under the Plan if such change
exceeds 10% from the prior month in any Policy month or 20% over any three consecutive months regardless of
Policy Year.
This Amendment overrides anything to the contrary contained in the Policy/Contract/Agreement. All
Policy/Contract/Agreement provisions not addressed by this Amendment shall remain in full force and effect.
Where a conflict exists between the Amendment provision and a Policy/Contract/Agreement provision, the
Amendment provision shall control.
This Amendment is effective on and after January 1, 2007. The Company has executed this Amendment at its
Executive Office on December 6, 2006.
• GREAT-WEST LIFE &ANNUITY INSURANCE COMPANY
rte.
• Secretary President
Accepted by:
Weld County Government
Signature: Title: Date:
Note: It is the Policyholder's/Contractholder's responsibility to promptly review the documents within 60 days of
receipt. If you have not communicated to us in writing within the above time frame, it will constitute your
acceptance of this Amendment/replacement to the Policies/Contracts/Agreements as submitted.
•
•
GREAT-WEST LIFE & ANNUITY INSURANCE COMPANY
Executive Offices—Greenwood Village, Colorado
(Company)
• Administrative Services Contract
issued to
Weld County Government
(Contractholder)
The above Administrative Services Contract No. 0258610 is amended as follows:
DELETION OF 10/20 RULE WITH MINIMUM MONTHLY ATTACHMENT
Section 4.8.2(e):
e) if there is a change in the number of Members covered under the Contractholder's Plan for any
Coverages provided under the Contractholder's Plan which equals or exceeds:
(i) 10% in any Contract Month when compared to any prior Contract Month; or
(H) 20% over any period of three consecutive months.
is hereby deleted in its entirety.
This Amendment overrides anything to the contrary contained in the Policy/Contract/Agreement. All
Policy/Contract/Agreement provisions not addressed by this Amendment shall remain in full force and effect.
Where a conflict exists between the Amendment provision and a Policy/Contract/Agreement provision, the
Amendment provision shall control.
•
This Amendment is effective on and after January 1, 2007. The Company has executed this Amendment at its
Executive Office on December 6, 2006.
GREAT-WEST LIFE & ANNUITY INSURANCE COMPANY
/7„,-/7
Vice President
Accepted by:
Weld County Government
Signature: Title: Date:
Note: It is the Policyholder's/Contractholder's responsibility to promptly review the documents within 60 days of
receipt. If you have not communicated to us in writing within the above time frame, it will constitute your
• acceptance of this Amendment/replacement to the Policies/Contracts/Agreements as submitted.
COBRA ADMINISTRATIVE SERVICES AGREEMENT
• by and between
Weld County Government
(Herein called the Contractholder)
and
GREAT-WEST LIFE &ANNUITY INSURANCE COMPANY
(Herein called the "Company")
The Contractholder sponsors a group health plan (hereinafter called "the Plan") for its Members, and desires that
the Company perform certain administrative services in connection with continued coverage (hereinafter called
"COBRA") for eligible Plan beneficiaries as identified by the Contractholder (hereinafter called "Plan
beneficiaries").
In consideration of the payment to the Company of the fees stated in the Payment Schedule, subject to the terms
and conditions of this Agreement, the Contractholder and the Company agree as follows:
Section 1. Definitions
As used in this Agreement, its Appendices and Attachments, unless otherwise specifically provided:
A. "COBRA" means the continuation coverage offered in accordance with the Consolidated Omnibus Budget
Reconciliation Act of 1985, as amended from time to time.
• B. "Commencement Date" means the date on which The Company begins rendering services other than
initial setup under this Agreement, which date shall be as soon as reasonably practicable after
Contractholder supplies The Company with all information needed to accomplish the initial setup of the
Services, as set forth in Section 2. Paragraph A. herein.
C. "Effective Date" means the last date of execution or date of deemed execution of this Agreement by the
parties.
D. "Member" means any employee, or covered dependent if any, as defined by the Plan whose coverage
under the Plan is being continued under the COBRA health continuation provision of the Plan.
E. "Plan beneficiary" means the employee covered under the Plan or the spouse or dependent children of a
covered employee covered under the Plan but has not experienced a Qualifying Event.
F. "Qualified Beneficiary" means a Plan beneficiary who has experienced a Qualifying Event or children born
to or adopted by a covered employee during a period of COBRA coverage. Qualified Beneficiaries
include:
1. COBRA participants who have paid their premium and COBRA participants who have not paid
their premium and are still within the grace period allowed under COBRA;
2. Qualified Beneficiaries who have experienced a Qualifying Event and have been provided an
election notice within the prior 60 days but have not yet submitted an election form;
3. Qualified Beneficiaries who have experienced a Qualifying Event in the prior 30 days but have not
been provided an election notice.;
G. "Qualifying Event" means the following events which, but for COBRA, would result in the loss of coverage
of a Qualified Beneficiary:
1. Death of the covered employee;
• 2. The termination (except for gross misconduct) or reduction of hours of the covered employee's
employment;
3. The divorce or legal separation of the covered employee from the employee's spouse;
4. The covered employee becoming entitled to benefits under Medicare;
1
5. A dependent child ceasing to be a dependent child under the generally applicable requirements
of the plan;
6. Bankruptcy of employer in certain instances.
• Section 2. Services
The Company shall provide the following services and Contractholder shall have the following responsibilities in
connection with the administration of COBRA for Plan beneficiaries:
A. Initial Setup.
1. Set-up of Necessary Information by The Company. As soon as practicable on or after the
Effective Date, or such later-date as may be agreed to by the Parties, The Company shall
establish on its corporate systems all demographic, eligibility and other information necessary to
enable The Company to conduct the Services set forth in this Agreement. The Company is not
responsible for COBRA administration before the Commencement Date and not until initial setup
of this information is completed.
2. Initial Information from Contractholder. The Company's obligation to establish the information
set forth in sub-section Al.. is subject to, and expressly conditioned on, Contractholder providing
such information to The Company in such reasonable detail and in such format as set forth in this
Section 2. For the purposes of initial setup, Contractholder shall provide the following information:
a. A list of all Qualified Beneficiaries eligible for COBRA; Contractholder shall update list so
that it is current as of the Commencement Date.
b. Eligibility information on each Qualified Beneficiary including:
1. Name;
2. Social Security Number;
•
3. Address;
4. Date of birth;
5. Dependent(s), if any (i.e. Name, Social Security Number, Address and Date of
birth of each);
6. All Benefit Options for which The Company will be billing Qualified Beneficiary;
7. COBRA start date and the date which COBRA will end;
8. Last date for which COBRA premium has been paid;
9. Termination reason.
c. A list of any non-The Company benefit options for which COBRA will be available and for
which The Company will administer COBRA and a list of any existing COBRA
participants on the non-Company benefit options updated until the Commencement Date.
d. Confirmation of rates that will be charged to Qualified Beneficiaries for COBRA including
both the rate for The Company benefit options and non-Company benefit options.
Contractholders must provide their own rates at least 10 days before Commencement
Date of COBRA administration by The Company.
e. If Contractholder was using a COBRA administrator prior to The Company providing
COBRA administration services the prior COBRA administrator's contact information.
f. A list of any Plan participants who have commenced coverage under the Plan on the
Commencement Date of COBRA administration with the Company who require a
General Notice.
3. Contractholder Responsibilities During Initial setup. In addition to the information that
• Contractholder will provide as described in sub-section A. 2 Contractholder will also have the
following responsibilities during initial setup.
2
a. Coordination with Prior Carrier and COBRA Contact. Contractholder must facilitate
coordination with any prior COBRA administrator and with designated COBRA contact so
the Company may obtain information necessary to complete initial setup. If there was a
• prior COBRA administrator the Company will contact Contractholder's prior COBRA
administrator to obtain information required for initial setup. If Contractholder did not have
a prior COBRA administrator the Company will contact the COBRA contact designated
herein to obtain information required for initial set-up. Contractholder is responsible for
any authorizations required by prior COBRA administrator to transfer such information to
the Company. The Company will not be responsible for any prior COBRA administrator's
failure to cooperate with the Company and Contractholder remains responsible for
facilitating initial set-up.
b. Notification. Contractholder must notify current Qualified Beneficiaries and all Plan
beneficiaries that future COBRA administration has been transitioned to the Company.
Such notification by Contractholder should take place as soon as practicable, but no later
than 15 days after the Effective Date of this Agreement.
c. Initial Setup of Future Changes. After the Commencement Date of COBRA
administration with the Company Contractholder may change between the different levels
of COBRA administration services that the Company offers at any time but must allow the
Company 30 days, or a longer amount of time as agreed to by the parties, to complete
initial setup required for the changes. Contractholder will provide any additional
information the Company requests in order to complete initial setup of any future changes
between the different levels of COBRA administration services. Contractholder must
notify the Company that it would like to change between different levels of COBRA
administration services in writing.
B. Basic Services. On or after the Commencement Date or such later date as may be agreed to by the
Parties, the Company shall provide the following services subject to and expressly conditioned on,
• Contractholder providing necessary information for Initial Set-up as described in Section 2.A and fulfilling
all Contractholder obligations as described in Section 3. Contractholder remains responsible for any
additional COBRA requirements not included in the following services.
1. Premium Billing Service. In order to collect the COBRA premium due to Contractholder from
Qualified Beneficiaries, the Company shall bill the Qualified Beneficiary who has elected COBRA
each month for the premium the Contractholder has specified plus the administrative fee allowed
by the COBRA law and regulations. Such bill shall indicate the coverage period being billed for,
the payment due date, the amount due for the coverage period, any amount due for prior
coverage periods, and the address to which payment should be sent, and that payments should
be made payable to Contractholder.
a. Remittance of Premium to Contractholder. The Company will make all commercially
reasonable efforts, in such manner as the Contractholder may reasonably direct, to
forward to Contractholder all payments received from Qualified Beneficiaries during the
previous calendar month for COBRA.
b. Premium Due Date and Grace Period. The Company will enforce the premium due date
which is the first(1st)day of each month. The Company will allow the 30-day grace period
that is mandated by the COBRA law and regulations. If the Company does not receive a
Qualified Beneficiary's payment postmarked within 30 days of the premium due date, the
Company will terminate COBRA for that Qualified Beneficiary and any persons covered
through him or her. Such termination is retroactive to the end of the period for which the
last required COBRA premium was paid. The Company will then send the Termination
Notice as described in sub-section 2.b. of this Section 2.B and notify the Contractholder
of the termination.
• 1. Non-Sufficient Funds and Bounced Checks. If a Qualified Beneficiary's
payment is dishonored for non-sufficient funds, COBRA law and regulations
require the Contractholder to allow cure by the Qualified Beneficiary in a
reasonable amount of time. The Company will send the Qualified Beneficiary
3
whose payment was dishonored a letter informing them of the dishonored
payment and offering cure in a reasonable amount of time but no longer than 10
business days from the date the notice is sent. If no cure is received the
• Company will terminate the Qualified Beneficiary's COBRA. The Company will
not accept a premium shortfall payment as described in sub-section B.1.c.3 of
this Section 2 as cure for non-sufficient funds and bounced checks.
Contractholder may direct the Company to require future payments from that
Qualified Beneficiary be made in the form of certified check or money order.
c. Non-Payment or Shortfall. If the Company does not receive payment or receives
payment less than the amount due:
1. Non-payment of Initial COBRA Premium. The Company will consider the
Qualified Beneficiary to have forfeited his or her right to continue COBRA if the
Qualified Beneficiary does not pay his or her initial premium within 45 days after
the Qualified Beneficiary elects COBRA. This forfeiture of COBRA rights will also
affect other family members whose election of COBRA was made through or
jointly with the Qualified Beneficiary's COBRA election.
2. Non-Payment of Monthly COBRA Premium. The Company will terminate
COBRA if a Qualified Beneficiary fails to pay any subsequent monthly COBRA
premium within 30 days of the payment due date. Coverage for that Qualified
Beneficiary and any persons covered through him or her will end as of the end of
the period for which the last required COBRA premium was paid.
3. Premium Shortfall. As required by the COBRA law and regulations, any amount
less than the initial COBRA premium due or less than the monthly COBRA
premium due will result in a premium shortfall and termination of COBRA unless
the premium shortfall is an insignificant premium shortfall that is equal to or less
• than the lessor of$50 or 10 percent of the COBRA premium required by the Plan
at which point the premium payment will not be considered late or reason for
termination. The Company will notify the Qualified Beneficiary of the amount of
the insignificant shortfall and grant thirty(30) days from receipt of the insignificant
shortfall payment for Qualified Beneficiary to pay the amount of the deficiency.
a. If the amount of the deficiency is not received within thirty (30) days from
receipt of the insignificant shortfall payment the Company will terminate
COBRA retroactively to the end of the period for which the last required
COBRA premium was paid.
2. Notices Included in Basic Services. The Company will send Qualified Beneficiaries the
following notices regarding their COBRA rights when such notices are required by the law and
regulations or when such notices are necessary to administer COBRA. Unless Optional Services
are elected Contractholder remains responsible for any other notices required by the law and
regulations such as the General Notice or Qualifying Event Notice.
a. Expiration Notice. In order to inform Qualified Beneficiaries of their exhaustion of
COBRA rights, within six months and again within thirty-days of the date the Qualified
Beneficiary's right to COBRA will end, the Company will mail to the Qualified Beneficiary
a statement informing the beneficiary of their COBRA expiration date and, if applicable,
his or her right to obtain individual conversion coverage, and whom to contact for
information about the details of such coverage and how to apply.
b. Termination Notice. Contractholder authorizes the Company to send a Notice of
Termination of COBRA("Termination Notice") as required by the law and regulations
after the Contractholder notifies the Company of the decision to terminate COBRA or
after the date the Company terminates COBRA as allowed by law.
• 1. Contractholder authorizes the Company to send a Termination Notice and/or to
terminate a Qualified Beneficiary's right to COBRA for the following reasons:
4
a. Qualified Beneficiary's failure to properly submit an election form;
b. Qualified Beneficiary's failure to pay premium on time;
c. Qualified Beneficiary obtains other Group Health Plan Coverage and
• requests termination;
d. Qualified Beneficiary first becomes entitled to Medicare after date of
COBRA election;
e. Qualified Beneficiary in Disability Extension found not disabled;
2. If Contractholder decides to terminate COBRA early for cause or for any other
reason not listed above then Contractholder must direct the Company in writing.
3. The Termination Notice will be a template developed by the Company that
complies with the law and any model notice that may be issued. The Termination
Notice will inform a Qualified Beneficiary that the plan administrator has decided
to terminate his or her COBRA, the reason for the early termination and the date
COBRA terminates.
c. Notice of Rate or Premium Changes. The Company will send a letter notifying Qualified
Beneficiaries if there are any changes in the rates that will be charged for COBRA at
renewal.
3. Reports.
a. Status Report. The Company shall provide to Contractholder monthly a status report
showing the name of each beneficiary, the amount billed, the amount received and
COBRA effective and termination dates.
C. Optional Services. Contractholder may elect and the Company will perform the additional services
("Optional") in this sub-section C as required by law, subject to and expressly conditioned on,
• Contractholder providing necessary information for Initial Set-up as described in Section 2.A and all
additional ongoing information as described in Section 3.A. If Contractholder at any time elects for the
Company to not perform these Optional Services Contractholder will be responsible for complying with
these aspects of the law and regulations.
1. General Notice. If elected, the Company will distribute a general notification of continuation rights
("General Notice") under COBRA as soon as possible but no later than 30 days from when the
Company is informed of a Plan beneficiary's commencement of coverage under the Plan.
2. Qualifying Event Notice. If elected and upon notification of a Qualifying Event, the Company
shall within 14 days or in the timeframe required by law, mail to Qualified Beneficiaries a notice
outlining their right to continue coverage under COBRA and an election form subject and
expressly conditioned on Contractholder providing information as described in Section 2.A.
3. Loss of Coverage/Qualifying Event. In order for the Company to administer COBRA upon
occurrence of a Qualifying Event, the Contractholder shall provide to the Company eligibility data,
transmitted electronically on at least a weekly basis for any Qualified Beneficiaries who
experience a loss of coverage under the Plan that is a Qualifying Event that triggers a legal right
to COBRA.
a. Contractholder's Duty to Notify the Company. Contractholder will include in such
transmission of eligibility data all required information necessary to administer COBRA
including name of plan, name of Qualified Beneficiary, coverage to be continued,
employee identification number, date of birth, address and spouse and/or dependents. A
Qualifying Event notice will be sent only once this information is received.
b. Contractholder's Duty to Provide Termination Reason. If not otherwise provided, the
Company will request from designated COBRA contact verification of the reason for loss
•
of coverage for each Qualified Beneficiary. Contractholder must provide and verify to the
Company the termination reason in order for the Company to determine if and what
Qualifying Event has occurred.
5
4. Unavailability Notice. Contractholder must notify the Company of any notice of a Qualifying
Event or a request for COBRA from an ineligible Plan beneficiary. Once Contractholder notifies
• the Company of unavailability, the Company will send a Notice of Unavailability of COBRA
Coverage ("Unavailability Notice") drafted to reflect the circumstances surrounding the
unavailability.
Section 3. Contractholder Obligations.
In order for the Company to perform COBRA administration for Contractholder, Contractholder has the following
ongoing obligations.
A. Duty to Inform. Contractholder must keep the Company updated with changes in information that affect
COBRA administration. This information includes:
1. Contractholder must provide the Company COBRA Administration Services updated
demographic information such as names, addresses or residences of each Plan beneficiary or
Qualified Beneficiary as the Plan is made aware of changes.
2. Contractholder must provide the Company with any formal notice affecting COBRA administration
that is delivered to the Plan instead of the Company.
3. Contractholder must provide the Company with the eligibility information described in Section
2.A.2.b for any new Qualified Beneficiaries. Contractholder remains responsible for providing
eligibility information and Contractholder shall do so as needed even if such information is
available on the Company's corporate systems.
B. Reasonable Procedures.
• 1. Distribute and Maintain Reasonable Procedures. As required by the law and regulations the
Plan will adopt and cooperate with Reasonable Procedures for Plan beneficiaries and Qualified
Beneficiaries to notify the Plan administrator of certain initial qualifying events, second qualifying
events and changes in personal demographic or eligibility information. It is the Contractholder's
responsibility to distribute and maintain Reasonable Procedures. The Company, where necessary
and where requested in writing by the Contractholder, will require proof from the Qualified
Beneficiary of certain qualifying events such as a copy of a divorce decree or a child support
order.
C. Designated COBRA Contact. Contractholder must maintain the COBRA contact designated herein in
order to facilitate the exchange of information between the Company and Contractholder. Any changes to
this contact person should be immediately provided in writing to the Company.
D. Exchanging Information. The Company will use standard workflows and procedures that may be
changed at any time by the Company to better facilitate administration of COBRA.
E. Duty to Provide Premium Rates. In order to determine and confirm rates that will be charged for
COBRA Contractholder shall provide or confirm all COBRA premium rates once during every 12-month
rate determination period. Contractholder may only change rates once during a 12-month rate
determination period or as allowed by law. Once rates are provided or confirmed by Contractholder, the
Company will not administer a different rate during the 12-month rate determination period. Any rate
changes must be communicated to the Company at least 45 days in advance of the change and no rate
changes will be retroactive.
F. Delays In Performance. Contractholder must promptly furnish information requested by the Company for
COBRA administration or as described in this Agreement. The Company shall not be responsible for
delay in the performance of its duties under this Agreement or for non-performance hereunder if such
delay or non-performance is caused or contributed to in whole or in part by the failure of the
• Contractholder to promptly furnish any required information. The Company will not be responsible for any
fines, penalties or damages resulting from Contractholder's delay in performance, failure to provide
accurate information or failure to maintain or distribute Reasonable Procedures.
6
G. Payments to the Company.
• 1. Billing and Payment. The Company shall bill the Contractholder in accordance with the Payment
Schedule for the services the Company performs under this Agreement. The Contractholder shall
pay the billed amount to the Company on the first(1s`) day of each month and will be considered
delinquent on the tenth (10th) day of each month.
2. Adjustment of Fees. The Company shall have the right to adjust its fees for the services
performed under this Agreement on the annual anniversary of this Agreement and annually
thereafter. The Company may from time to time offer additional services and determine
associated fees that will be charged upon election by Contractholder.
Section 4. Other Terms of Agreement
A. General Provisions.
1. Reasonable Care. The Company as service contractor shall use reasonable care and diligence
in the exercise of its powers and the performance of its duties under this Agreement, but shall not
be liable for any mistake of judgment or other action taken in good faith, or for any loss unless
resulting from its gross negligence.
2. Indemnification and Hold Harmless. The Contractholder shall indemnify the Company as
service contractor and hold the Company harmless against any and all loss, federal excise tax,
damage and expense, including court costs and attorneys'fees, resulting from or arising out of
claims, demands or lawsuits brought against the Company as a result of or in any way growing
out of its performance of services under this Agreement. The Company shall indemnify the
Contractholder and hold the Contractholder harmless against any and all loss, federal excise tax,
damage and expense, including court costs and attorneys'fees, resulting from or arising out of
claims, demands or lawsuits brought against the Contractholder as a result of the Company's
•
failure to perform the services outlined in this Agreement or for failure to mail out any COBRA
notices to Plan beneficiaries or Qualified Beneficiaries as described in this Agreement, unless
such failures were caused or contributed to by the Contractholder.
3. Delegation. All or some of the duties of the Company as Service Contractor under this
Agreement may, at the Company's sole discretion, be performed by a contractor of its choosing.
The Company will notify Contractholder in writing 30 days in advance of any delegation at which
point Contractholder may terminate this Agreement in writing with 15 days notice.
4. Contractholder Consultation on Unusual Circumstances. The Company shall consult with the
Contractholder, or the Contractholder's designated plan administrator or legal counsel in matters
that are beyond the ordinary or in the event a Plan beneficiary or Qualified Beneficiary disputes
any action taken by the Company in connection with its administration of COBRA for that
participant. In the defense of any legal action against the Company as service contractor brought
as a result of or in any way growing out of such administration, the Company will furnish the
Contractholder, its plan administrator and/or legal counsel all pertinent information regarding the
matter in dispute. The Company shall not be obliged to undertake the defense of any such legal
action.
5. Reliance on Reasonable Communications. The Company shall be entitled to rely upon any
communication believed by the Company to be genuine and to have been signed or presented by
the proper party or parties.
6. Written Notification Requirements:
a. Great West shall not be bound by any notice, direction, requisition or request regarding
COBRA administration unless and until it receives it in writing at the following address:
• Great-West Healthcare
Attn: COBRA Administration Services
7
P.O. Box 66803
St. Louis, MO 63166
• Great-West Healthcare is a subsidiary of Great-West Life & Annuity Insurance Company
b. Notices or communications to the Contractholder shall be to the Contractholder's
designated COBRA contact at the following address:
Weld County Government
Attn: Jewel Vaughn
915 10th Street , PO Box 758
Greeley, CO 80632
This should be the designated COBRA contact who the Company may use to exchange
COBRA information. Contractholder may provide additional contacts for the purposes of
COBRA in writing to the Company at anytime.
c. Either party may change its address from time to time by notice given to the other in
accordance with this paragraph.
7. Binding Terms of Plan. The Company shall have no power or authority to alter, modify or waive
any of the terms or conditions of the Plan, or to waive any breach of any such terms or conditions,
or to bind the Contractholder or to waive any of its rights, in any way whatsoever.
8. Limited Authority. The Company shall have no power or authority to act for or on behalf of the
Contractholder other than as herein expressly stated, and no other or greater power or authority
shall be implied by the grant or denial of power or authority specifically mentioned in this
Agreement.
• 9. Record Retention. The Company shall hold as the property of the Contractholder all papers,
books, files, correspondence and records of all kinds which at any time shall come into its
possession or under its control and which relate to the transactions it performs under this
Agreement. The Company shall surrender such records to the Contractholder upon termination of
this Agreement upon request. The Company will retain copies as required by law but usually
seven (7) years. The Company may periodically destroy such material as it would destroy its own
records of a similar nature in the normal course of its business.
10. Audit& Inspection Rights. The Contractholder shall have the right to inspect and audit at the
offices of the Company all documents that relate to the Company's performance of its duties
under this Agreement. All costs of such inspection(s) shall be borne by the Contractholder and be
subject to a reasonable written audit agreement provided by the Company.
11. Alteration & Modification. No alteration or modification of the terms and conditions of this
Agreement shall be valid or of any force or effect unless in each instance it is contained in a
writing expressing such alteration or modification and executed for the Contractholder and the
Company by their officers duly authorized to sign such alteration or modification.
12. Entire Agreement. This Agreement, including any appendices or supplements thereto, shall
constitute the entire contract between the parties and shall govern the rights, liabilities and
obligations of the parties hereto except as it shall be modified in accordance with paragraph [11]
in this Section 4.
13. Administrative Function. It is understood that under this Agreement the Company performs
purely administrative functions for the Contractholder within a framework of the Administrative
Services Agreement. Any review by the Company of any action it has taken with regard to
continuation of coverage for a Plan beneficiary or a Qualified Beneficiary is made as a service for
the Contractholder, who retains the final responsibility for determining what action(s)to take in the
• administration of the Plan. The Company does reserve the right to use good faith judgment and
make final determinations of all billing disputes, coverage and eligibility determinations for
Qualified Beneficiaries if necessary to comply with state or federal law.
8
14. Named Fiduciary. Under no circumstances shall the Company as service contractor be
considered the named fiduciary under the Plan.
• 15. Binding Nature and Assignment. This Agreement shall be binding on the Parties hereto and
their successors and assigns, but neither Party may assign this Agreement without the prior
written consent of the other, which consent shall not be unreasonably withheld.
16. Good Faith. The Parties agree to exercise good faith in the performance of this Agreement.
17. Force Majeure. A Party shall be excused from performance under this Agreement for any period
that Party is prevented from performing any services pursuant hereto, in whole or in part, as a
result of an Act of God, war, civil disturbance, court order, labor dispute or other cause beyond its
reasonable control, and such nonperformance shall not be grounds for termination.
18. Attorney's Fees. Except as otherwise specified in this Agreement, if any legal action or other
proceeding is brought for the enforcement of this Agreement, or because of an alleged dispute,
breach, default, misrepresentation, or injunctive action, in connection with any of the provisions of
this Agreement, each Party shall bear its own legal expenses and any costs incurred in that
action or proceeding.
19. Disposition of Data. Except as described in Paragraph 10. The Company will not be responsible
for storing copies of Contractholder's records when the Company no longer requires such
information in order to provide Services to Contractholders. Contractholder will reimburse the
Company for the costs of reproducing any information in the Company's possession or control
relating to Contractholder's business or employees that the Company is obligated to produce in
response to a Contractholder request or court order. Upon termination of this agreement, the
Company will retain and dispose of Contractholder's records and data according to the
Company's Record Retention Policy unless otherwise previously directed in writing by the
• Contractholder.
20. Intellectual Property. All materials, including but not limited to forms, brochures, posters and
online content("Materials") furnished by the Company are licensed and not sold to
Contractholder. Contractholder is granted a personal, non-transferable and nonexclusive license
to use Materials solely for Contractholder's own internal business use. Contractholder does not
have the right to copy, distribute, reproduce, alter, display or use these Materials or any of the
Company trademarks for any other purpose. Contractholder agrees that it will keep materials
confidential and use commercially reasonable efforts to prevent and protect the content of
Materials from unauthorized use and its license to use Materials ends on the termination date of
this Agreement. Upon termination, Contractholder agrees to not use and destroy Materials or if
requested by the Company, return them to the Company.
21. Mail. All Notices and Documents will be sent via First Class Mail as allowed by the law
regulations.
22. Legal Advice: The Company will utilize support of the the Company law department in the scope
of COBRA administration. The Company cannot provide legal advice to the Contractholder
outside of the scope of their COBRA administration. No actions or recommendations should be
construed as legal advice and Contractholder should always consult their own legal counsel on all
legal questions.
23. Administrative Services Agreement: This agreement will not supercede any provisions of the
Administrative Services Agreement for claims payment between Contractholder and the
Company. The Administrative Services Agreement will govern in any conflict with this Agreement.
B. Confidentiality and Privacy.
1. Privacy. Contractholder and the Company agree to adhere to any applicable federal or state
• privacy laws. Contractholder and the Company agree they have entered into any necessary
agreements, such as a Business Associates Agreement as required by the Health Insurance
9
Portability and Accountability Act("HIPAA"), to share confidential or protected health information
between each other or the Company.
2. Confidentiality. All information and data delivered to the Company pursuant to this Agreement
shall be deemed to be Confidential Information unless otherwise specified in writing by the
Company.
C. Controlling Law.
1. Choice of Law. This Agreement shall be governed and construed by the law of the State of
Colorado on all matters (without giving effect to principles of conflicts of laws), except to the
extent that HHS Privacy Regulations or Federal COBRA Regulations may supersede such state
law. Any disputes arising out of this Agreement shall be adjudicated exclusively by an appropriate
federal or state court sitting in Arapahoe County, Colorado.
D. Separability.
1. If any provision of this Agreement is determined to be illegal or invalid for any reason by law or a
court of competent jurisdiction, such illegality or invalidity shall not affect the remaining parts of
this Agreement, and they shall be construed and enforced as if said illegal or invalid provision(s)
had not been included herein, provided the basic purposes of the Agreement can be effectuated
through the remaining valid and legal provisions.
2. Failure by the Contractholder or the Company to insist upon compliance with any provision of this
Agreement at any time or under any circumstances shall not operate to waive or modify such
provision or render it unenforceable as to any other time or circumstance, and no waiver of any of
the terms or conditions of this Agreement shall be valid or of any force or effect unless contained
in a writing signed by a person duly authorized to sign such waiver.
3. This Agreement is drafted in accordance with the Federal Consolidated Omnibus Budget
• Reconciliation Act of 1985 ("COBRA") as amended from time to time and all associated
regulations and guidance. The terms of this agreement and administration by the Company may
change in accordance to any changes in the law or guidance issued regarding COBRA or any
related laws. Any continuation coverage administered in accordance with state continuation
coverage laws or other federal continuation coverage laws, where appropriate, will be
administered when requested in writing by Contractholder, subject to an appendix or a separate
agreement and according to additional fees or the payment schedule attached to this agreement.
E. Counterparts.
1. This Agreement may be executed in any number of counterparts, each of which shall be deemed
an original, and said counterparts shall constitute but one and the same instrument.
F. Termination.
1. If any state or other jurisdiction enacts a law that prohibits the continuance of this Agreement, or
existing law is interpreted to so prohibit the continuance of this Agreement, the Agreement shall
terminate automatically as to such time or jurisdiction on the effective date of such law or
interpretation.
2. Either party may terminate this Agreement as of any anniversary of its effective date by giving at
least 31 days' prior written notice to the other party.
3. The Company as Service Contractor may terminate this Agreement if the Contractholder defaults
in the timely payment of any amount due under this Agreement and, after having been given
notice of such default, fails to cure its default within ten working days of the date of such notice.
Termination of this Agreement for the reason described in this paragraph 3 shall be effective
•
immediately upon the Contractholder's receipt of written notice of termination from the Company.
10
In witness whereof, the parties have caused this Agreement to be executed by their respective officers duly
authorized to do so, to be effective as of January 1, 2007.
• Weld County Government
(Contractholder)
By: See Declaration of Signature
Title: See Declaration of Signature
Date: December 6, 2006
GREAT-WEST LIFE & ANNUITY INSURANCE COMPANY
Vice President
Date: December 6, 2006
GA-COB RA-ADM I N-(4-00) (Rev. 09-02)
•
•
11
PAYMENT SCHEDULE
To be attached to and made a part of the Agreement by and between:
Weld County Government
and
GREAT-WEST LIFE &ANNUITY INSURANCE COMPANY
The Contractholder shall make payments to the Company in advance for service fees listed below by the first day
of each Plan Month in which the Company performs duties pursuant to this Agreement. A grace period of 30 days
is granted after such monthly payment due date.
The amount due will be determined as follows, in addition to $0.70 per employee per month which is billed as part
of your monthly ASO Administration Fee.
Additional Fees
General Notices Not Applicable
Qualifying Event Notices (per notice) Not Applicable
Monthly fees for monthly billing service. Not Applicable
•
•
12
Great-West®
• HEALTHCARE
Great-West Life & Annuity Insurance Company
Application for Group Coverage for
Weld County Government
Policy Number: 358610
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Summary of Amendment: Increasing SSL level to $150,000. Adding 90% Minimum Attachment.
Deleting Ceridian COBRA Services and adding GW In-House COBRA Services.
Does this amendment include a Policyholder Name change or EIN/TIN change? Yes ® No
If Yes, is this due to a merger or acquisition? Yes I No
Full Legal Name of Firm: Is this company subject to ERISA? ❑Yes ®No
Weld County Government
Company Type:
Late of Situs: CO El ❑Corporation Partnership
militate
ID/EIN: S-Corp ❑Association
Requested Effective Date: January 1, 2007 ®Government ❑Non-Electing Church Group
❑Public/Non-Profit Limited Liability Corp. (LLC)
Individual/Unincorporated Business/Proprietorship
Industry:
SIC: ERISA Plan Number:
ERISA Plan Year:
Will the health plan cover the employees of two
or more employers or be otherwise considered a
Multiple Employer Welfare Arrangement
(MEWA)? Yes ❑ No L':
If yes, click on help information and fill out below
Owner Ownership %
Company Name for ID Cards (Must be abbreviated to 30 digits):
•
mstrapp(Mar-01 -2002)-Weld County Govemme-IG W I,A M IDGRACOA I 1142006
Applicant Information:
Applicant's Street Address: Subsidiaries:
915 10th Street Name Ownership% SIC Code
4111O BOX 758
City: GreeleyState: CO Zip: 80632
BENLink Use: nNo ❑Yes (Internet Explorer 5.0 or greater required,indicate user/system info for each contact)
Plan Administrator: (receives Legal/Formal Contact: Cobra Contact:
routine correspondence) ❑ Same as Plan Administrator ® Same as Plan Administrator
Plan Administrator: ❑Mr. EMs. ❑Mr. EMs.
❑Mr. EMs. Name: Name:
Name: Title: Title:
Title: Phone: Fax: Phone: Fax:
Phone: Fax: E-mail: E-mail:
E-mail: ❑BENLink User ❑BENLink User
❑BENLink User SSN: SSN:
SSN: ISP: Connect via: Modem ISP: Connect via: Modem
ISP: Connect via: Modem Address:(IF DIFFERENT FROM Address:(IF DIFFERENT FROM
Address: (CHANGE IF DIFFERENT FROM APPLICANT ADDRESS) APPLICANT ADDRESS)
APPLICANT ADDRESS)
,
FSA Contact: Additional Contact: Additional Contact:
,1 Same as Plan Administrator
Reason for Contact: Reason for Contact:
Reason for Contact: ❑Mr. EMs. ❑Mr. ❑Ms.
❑Mr. OMs. Name: Name:
Name: Title: Title:
Title: Phone: Fax: Phone: Fax:
Phone: Fax: E-mail: E-mail:
E-mail: ❑BENLink User ❑BENLink User
❑BENLink User SSN: SSN:
SSN: ISP: Connect via:Modem ISP: Connect via:Modem
ISP: Connect via: ModemAddress: Address:(IF DIFFERENT FROM Address:(IF DIFFERENT FROM
(IF DIFFERENT FROM APPLICANT ADDRESS) APPLICANT ADDRESS) APPLICANT ADDRESS)
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nistrapp(Mar-01-2002)-Weld County Govemrne-IGW LAMIDGRACOA11142006 2
• :.Applicant Information:
Employee Data: Employee state #of State #of
Code Fes Code Ges
Total(including those in the waiting period): Residence:
Indicate residency
Illotal eligible for medical coverage: outside U.S.here:
Total currently under medical coverage: Indicate all states
where employees
Total number of retired employees: reside:
State #of
Code 1?es
Total employees residing outside the U.S:
Percent of the employees speaking a language other than
English:a)❑ 10%or more for groups>100 lives; OR
25%or more for groups< 100 lives
b)❑ Less than the percents stated above.
If answer is a)above,which language?
Disabled Employees/Employees not actively at HMO Option:
ork: Do you currently offer a Non-ONE Health Plan HMO?
o you have Disabled Employees and/or Employees not ❑No ❑Yes
actively at work? ❑Yes ❑No
For an ERISA plan,Great-West will have full discretion and authority to interpret the Plan and determine whether a
claim should be paid or denied on appeal and according to the provisions of the Plan as set forth in the Summary Plan
Description.
,iRmPerformance Guarantees: : ,r.
Performance Guarantees: Have performance guarantees of any type been sold to this client?
❑Yes❑No
If yes, the proposed guarantee schedule(s)must be submitted to Plan Services at the same time as the Master Application.
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Banking Information: ::::::::_::._iri�i£:litlijr.... .₹i.E: ,.., .,.. - 3!sii!,R!! . • ....x.� •xx.�en:�:S:S:y£5t:Y�.'k1L3�prr�..^rau� .
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Banking Options:
❑ Daily ❑ Weekly ❑ Weekly w/1 week delay
*Eff 5/1/03-Mid 500 cases w/Preferred Funding can not choose Weekly w/week delay
mstrapp(Mar-01 -2002)-Weld County Govemme-1GWLAMIDGRACOA11142006 3
COBRA Information:
COBRA Services Administrator: Maximum period of coverage to begin on:
® Great-West Healthcare ❑date of the qualifying event
Ceridian COBRA Standard Service Zdate of loss of coverage
Ceridian COBRA Enhanced Service
❑ Other
** If Great-West Healthcare is the COBRA Administrator, Please complete the following section:**
COBRA Services: COBRA Participants:
❑ Basic—monthly billing service only Number of existing COBRA participants: 7
® Optional—monthly billing and notices
Send Participant Checks to: Client
If Optional, the Service Package Includes the following selection(s):
® COBRA General Notices
® COBRA Qualifying Event Notices
Ceridian:
Is this a prior Ceridian client? ® Yes ❑ No
Non-Great-West Benefits:
Is GWHC administering COBRA Services for non-GWHC benefits? ❑Yes ®No
(It is the employer's responsibility to report all COBRA General Notices or Qualifying Event Notices needed,as eligibility data
on this membership is not retained by Great-West)
If yes, did Ceridian administer COBRA services for non-GWHC benefits? ❑ Yes ❑No
For the plans that GWHC is administering COBRA for non-GWHC benefits, list all Plans below including the COBRA rate
tructure with the currentcarrier(IE: single rate or combined rate):
edical Plan(s): Dental Plan(s):
(s): Vision Plan(s): Cobra Contact:
endor: Vendor: Vendor:
Applies to: Applies to: Applies to:
❑All ees ❑All ees ❑All ees ❑Mr. ®Ms.
❑Omer- O Other- ❑Omer- Name: Jewell Vaughn
COBRA Rates: COBRA Rates: COBRA Rates: Title: Personnel
❑By Benefit ❑By Benefit ❑By Benefit
❑Combined with other benefit(s) ❑Combined with other benefit(s) ❑Combined with other benefit(s). .,. Phone: 970-356-4000
Medical Plan: Dental Plan: Vision Plan: ex 4231
Vendor: Vendor: Vendor: Fax: 970-352-9019
Applies to: Applies to: Applies to:
E-mail:
❑All ees ❑All ees ❑All ees
❑Other- 5 Other- ❑Other- ivaughntw,co.weld.co.0
COBRA Rates: COBRA Rates: COBRA Rates: s
❑By Benefit ❑By Benefit ❑ By Benefit
❑Combined with other benefit(s) 5 Combined with other benefit(s) ❑Combined with other benefit(s)
Medical Plan: Dental Plan: Vision Plan:
Vendor: Vendor: Vendor:
Applies to: Applies to: Applies to:
S All ees ❑All ees ❑All ees
❑Other- ❑Other- ❑Other-
COBRA Rates: COBRA Rates: COBRA Rates:
❑ By Benefit ❑By Benefit ❑By Benefit
❑Combined with other benefit(s) ❑Combined with other benefit(s) ❑Combined with other benefit(s)
Reporting Frequency: Report Sorting:
Frequency of Status Report: Monthly Status Report to be Sorted by:
Group/Billing Account/Name
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mstrapp(Mar-01 -2002)-Weld County Govemme-IG W LAM IDGRACOA 11142006 4
Plan/Class/Eli ibil .y Information: .. . :. .: .:: . �:: ° :`.:;.:
g 'i:i.
Annual Open Enrollment/Plan Transfers: from to
Late Applicants:
• Dare able to enroll only during annual open enrollment period. (Automatic for HMO. Coverage
becomes effective the first day of the month following the open enrollment period.)
Reinstatement after termination: Option to Waive Employee Benefits:
❑3 Months ❑Waiver of benefits not allowed ❑Waiver of benefits
allowed
Definition of Earnings:
(applies to Life Insurance(if multiple of salary),Short Term Disability,and Long Term Disability as selected by Applicant)
Basic rate of pay exclusive of overtime and bonuses in effect on: lithe first day of the month
Don a specific date
Are annual commissions to be included in the rate of pay?
[Wes ❑No
Commissions calculated:
❑12 times average monthly commissions received during preceding calendar year
Other:
itefinition of Retirees:
Are Retirees Covered? ❑ Yes ❑ No
Benefits:
❑Life ❑Medical ❑ Dental ❑Vision
Minimum Age Requirement is:
_years of age
❑No Minumum age
[employee retired,not receiving pension nemployee retired, receiving pension
nemployee retired,on pension&has completed years of service
nemployee retired,without pension&had completed years of service
Other:
Maximum Retiree Medical Benefits,all conditions,
Calendar Year/Lifetime Maximum: (Maximums do not apply to HMO or One+Plans)
❑$10,000/S25,000 ❑$25,000/$50,000 ❑ S50,000/$100,000
III
mstrapp(Mar-01 -2002)-Weld County Governmc-IGWLAMIDGRACOA1 1142006 5
Plan/Class/Eligibility Information:
Employer Contributions:
Name of Class 1:
rfe/AD&D Plan:
['Contributory (employee contributes a portion of costs for life Ian)
Employer contributes the following percentage(s): EE % Dependent %
Employee contributes the following percentage(s): EE % Dependent %
TOTAL must = 100% 100%
[Non-Contributory(employer contributes 100%of costs for life plan)
Health Plan(s):
❑Contributory(employee contributes a portion of costs for healt plan)
Employer contributes the following percentage(s): EE % Dependent_%
Employee contributes the following percentage(s): EE % Dependent %
TOTAL must = 100% 100%
❑Non-Contributory(employer contributes 100%of costs for health plan)
Name of Class 2 (if applicable):
Life/AD&D Plan:
['Contributory (employee contributes a portion of costs for life plan)
Employer contributes the following percentage(s): EE % Dependent %
Employee contributes the following percentage(s): EE % Dependent %
TOTAL must = 100% 100%
❑Non-Contributory(employer contributes 100%of costs for life plan)
Health Plan(s):
['Contributory(employee contributes a portion of costs for health plan)
Employer contributes the following percentage(s): EE_% Dependent %
Employee contributes the following percentage(s): EE % Dependent %
TOTAL must = 100% 100%
• ❑Non-Contributory(employer contributes 100%of costs for health plan)
Dependents: Covered ❑ Not Covered ❑
If Dependents are Employed by the Planholder: Dependents are defined as a legal spouse,
❑ They are covered as Employees Only. unmarried child under age 19
❑ * Spouses may be covered as both an Employee and a Dependent and unmarried full-time student
(benefits will be coordinated). Children are covered as Employees only. under age ❑ 23, ❑25
❑ * Spouses and children may be covered as both and Employee and a
Dependent(benefits will be coordinated).
*Options not available with the HMO Plan
Pre-Existing Conditions Limitation:
Did the prior plan have pre-ex limitation? ❑ Yes ❑No
(If no, any members covered under the prior plan will not be subject to any pre-ex limitation under this plan. If yes, any
members who satisfied the prior plan's pre-ex will not be subject to pre-ex limits under this plan.)
Is the Pre-existing limitation waived for existing employees? ❑Yes-underwriting must approve ['No
❑Std limit (Applies to: ALL medical plan benefits; any illness or injury up to 3 months prior to enrollment date.
Limitation is waived 12 months after enrollment date.)
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mstrapp(Mar-01 -2002)-Weld County Govemme-IG W LAM IDGRACOA 11142006 6
Plan/Class/Eligibility Information:'
Definition of Benefit Classes
Describe who is Eligible to Participate in Plan:
•ualifying Hours: per ❑week ❑month
®Double click for General Information and Eligibility Rules
Is the eligiblility waiting period waived for existing employees? ❑Yes-underwriting must approve ❑No
Class Description Waiting Period/Termination* Benefits NOT included for this class
(Include qualifying hours if different from Days from hire date OR
above)
A 151 of month coinciding with or
following hire date OR
❑i n of month following Days
B. Days from hire date OR
❑I S'of month coinciding with or
following hire date OR
151 of month following Days
C. Days from hire date OR
❑1 n of month coinciding with or
following hire date OR
15'of month following Days
*Termination of coverage is effective upon the date of the termination if the"#of days from hire date" is selected. If either
"IS'of the month..." option is selected,terminations are effective the last day of the month in which the termination occurs.
Change in Classes and amounts of Coverage Effective on:
❑ Date of change in status.
iiFirst day of the month coinciding with or next following the date of change.
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mslrapp(Mar-01 -2002)-Weld County Govemme-IG W LAM IDGRACOA I 1142006 7
Plan/Class/Eligibility Information:
•
Class Benefit Schedule: Life/AD&D Flat (If applicable)Short (If applicable)
Amount or Term Disability Long Term Disability
Class Description Percent of Salary— Flat Amount or Percent Percent
• rounded to next$l,0(K) of Salary
1. ON/A 050%
060% 066 2/3%
To Max _ Wkly Max
ON/A 050%
060% ❑GG 2/3%
'1'o Max _— Wkly Max3.
ON/A ❑50%
To Max Wkly Max 060% ❑66 2/3%
Divisional Billing:* *:1 minimum of 25 employees in each division is required.
Division Name 13il1ing Address Contact Name& Phone
Divisional Medical Claims: *A minimum of 25 employees in each division is required
(Prescription claims are not divisionalized)
Division Name Billing Address Contact Name&Phone
,,,,,,,,, ,
1 JI{�Iti:J. b :: St•T T T:......7 IIr.'.
n„,
Graded Preferred 25/50/100/125 Funding: (subject to state mandated minimums)
Adding Deleting ® Changing n�1,r 'n
(based on number of employees with Medical coverage) Aggregate Attachment: Pick One...:
Specific Stop-Loss: $150,000
Minimum Monthly Attachment: * (effective 4/1/06)
ENJ=$20,000 minimum if under 50 lives ®90% ❑95% ❑100%
❑NY=$25,000 minimum
❑CO=$15,000 minimum Minimum Terminal Attachment:* same as
❑FL&MD=$20,000 minimum minimum monthly attachment.
Aggregate limitation factor(ALF): *Applies in 2"and subsequent years
❑10%
❑None Other:
S
mstrapp(Mar-01 -2002)-Weld County Govcmmc-IGWLAM IDGRACOA 11142006 8
Application For Amended Group Coverage -- Signature Pages:
NOTE: This document is important.It affects your legal rights and obligations.
This Application is for employee benefit coverage and/or plan administrative services provided by Great-West Life &
Annuity Insurance Company(Great-West)or one of its affiliates.
Cher Benefits: ❑None
f there are any additional benefits not previously indicated,please identify them here. In the Benefit column, list coverage
affected,then in Description column describe the benefit. There will be an extra cost for each additional benefit listed. You
may list up to 4 additions. fl
Benefit Description
The Applicant understands that Great-West will provide amended Booklets, if any, electronically to the Applicant. The
Applicant is responsible for distributing booklets(electronically or otherwise)to employees.
State law of Colorado requires the following notice:
It is unlawful to knowingly provide false,incomplete,or misleading facts or information to an insurance company for the
purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment,fines,denial of
insurance,and civil damages. Any insurance company or agent of an insurance company who knowingly provides false,
incomplete or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting
to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be
reported to the Colorado division of insurance within the department of regulatory agencies.
The undersigned("the Applicant")hereby authorizes Great-West to amend the contracts and policies issued by Great-West,as
specified in this Application. Such amendments to the policies,contracts,or booklets is to be effective January 1,2007. Great-
West agrees to deliver the documents in a timely manner.
�t is the Applicants responsibility,upon receipt of the amendment to the contract or policy or the booklet,to promptly review the
amendment within a reasonable time,but not to exceed 60 days from the date of the cover letter, containing the amendment, is
sent to the Applicant. If the Applicant agrees and accepts the amendment,the Applicant must sign and return the
amendments within 60 days from the date of the cover letter. If the Applicant disapproves, the Applicant must contact us
within 60 days from the date of the cover letter. If the Applicant fails to communicate with us within the time frame
specified above, it will constitute the Applicant's acceptance of the amendment as submitted. In such event,the Applicant's
signature given below is also intended hereby as the Applicant's execution of the amendment
Full Legal Name of the Firm:f Weld County Government Effective Date: January 1,2007
ir By: (Printed Name) : /" ' Cl- e,4-
)) �
Applicant Signature: - ////Ail
'// a./1.
Title: eAIQZll1 �iC (// i ////S7Q.�
A Dated:
cant ri fry/S Si Mein
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mstrapp(Mar-01 -2002)-Weld County Govemme-[G W LAM IDGRACOA I 1 142006 9
I
XMc****Mc****McMct********* c************x*************x******Ac*********x*******x******************x*****
* P. 01 *
* TRANSACTION REPORT *
* NOV-15-2006 WED 03:46 PM *
* *
* FOR: WELD COUNTY PERSONNEL 9703529019 *
*
1. DATE START RECEIVER TX TIME PAGES TYPE NOTE M# DP *
* *
* NOV-15 03:42 PM 913036941922 4' 16" 10 SEND OK 012 *
* Y
z *
* TOTAL : 4M 168 PAGES: 10 *
* *
**McffiX*************K*****tC>k*****************tt:KYX****tt*X*****ttttYY************************* t ****t
‘oiiit- FAX TRANSMISSION
qaP t, 44.1 \
• mime Weld County
Personnel Services/HR Department
Cc 1.OE.ADO Fax: 970-352-9019
Phone: 970-356.4000, ext.4231
To: Melinda Eversole—Great West Date: November 15,2006
Fax: 303-694-1922 Pages: 10
Phone:
From: Jewel Vaughn
Weld County Personnel/HR
Subject: Weld County Amendment - 2007
COMMENTS:
•
•
FAX TRANSMISSION
VIiD Weld County
COLORADO Personnel Services/HR Department
Fax: 970-352-9019
Phone: 970-356-4000, ext. 4231
To: Melinda Eversole— Great West Date: November 15, 2006
Fax: 303-694-1922 Pages: 10
Phone:
From: Jewel Vaughn
Weld County Personnel/HR
Subject: Weld County Amendment - 2007
• COMMENTS:
CONFIDENTIAL
This facsimile is intended only for the use of the individual or entity to which it is addressed and
may contain information that is privileged, confidential, and exempt from disclosure under
applicable law. If the reader of this facsimile is not the intended recipient nor the employee or
agent responsible for delivering the facsimile to the intended recipient, you are hereby notified
that any dissemination, distribution, or copying of this communication is strictly prohibited. If
• you have received this communication in error, please notify us immediately by telephone and
return the original message to us at the above address via the U.S. Postal Service. Thank you.
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