HomeMy WebLinkAbout000358.tiff Cigna Client Application
Life Insurance Company of North America -;°►Fa
Connecticut General Life Insurance Company
Cigna Life Insurance Company of New York Cigna
UNDERWRITING COMPANY
Life Insurance Company of North America • Connecticut General Life Insurance Company
• Cigna Behavioral Health, Inc. (for Life Assistance • Cigna Life Insurance Company of New York
Program and Employee Assistance Program)
Documents for Customer Signature
Appointment of Claim Fiduciary ❑ Life Assistance Program Agreement
• Employee Assistance Program Agreement • Cigna Absence Assistant Agreement
Document for Client Review
O Benefit Reduction Schedule Notice 1 . Privacy Notice
[r Disclosure of Producer Compensation Practices D Disability Tax Service Agreement
To assure operational readiness and accurate set- up of your contract/agreement(s) please provide the information requested below.
EMPLOYER INFORMATION SECTION 1
Complete for all coverages
EMPLOYER FULL LEGAL NAME Please include exact abbreviations, punctuation and/or capitalization. COMPANY TAX ID tt
Weld County Government 84-6000813
STREET ADDRESS I CITY STATE ZIP CODE
1150 O Street Greeley CO 80631
PRIMARY CONTACT TITLE PHONE PHONE EXT. FAX
Staci Datteri-Frey Benefits Manager 970-400-4235
Email:
sfrey@weldgove.com
AFFILIATED COMPANIES
Are there employees eligible for coverage working for an affiliated company? • Yes No
If yes, please complete the following information.
AFFILIATE NAME (1) TAX ID ti SEPARATE BILUNG GROUP? NUMBER OF EMPLOYEES
■ Yes ■ No
STREET ADDRESS CITY STATE I ZIP CODE
1 -
CONTACT NAME PHONE PHONE EXT.
E- MAIL
if more space is needed for additional affiliates, billing groups or contacts, please provide the information requested above on the Additional Notes page.
GENERAL. PLAN AND COVERAGE INFORMATION .- SEC11ON 2
Complete for all coverages
Policy Effective Date(s) January 1, 2018 Policy Anniversary Date(s) 1/1/2020 (STD) 1/1/2021 (Life, AD&D & LTD)
0OO 35g
Page 1 of 11
GENERAL PLAN AND COVERAGE INFORMATION - SECTION 2 (Continued)
Complete for all coverages
Active Service Definition
An Employee will be considered in Active Service with the Employer on a day which is one of the Employer's scheduled work days if
either of the following conditions are met.
He or she is actively at work. This means the Employee is performing his or her regular occupation for the Employer on a Full-time basis,
either at one of the Employer's usual places of business or at some location to which the Employer's business requires the Employee to
travel . Applicable to all coverages
The day is a scheduled holiday, vacation day or period of Employer approved paid leave of absence, other than disability or sick leave
after 7 days. An Employee is considered in Active Service on a day which is not one of the Employer's scheduled work days only if he or
she was in Active Service on the preceding scheduled work day. Cigna standard is to not provide dual coverage for married couples.
Applicable only to Life and Accident Coverage.
The day is a scheduled holiday or vacation day and the Employee was performing his or her regular occupation on the preceding
scheduled work day. Applicable only to Disability Coverage.
Based on the above definition are there any employees who are not actively at work due to disability and are in the waiver waiting
period ? • Yes ❑ No If yes, please assist these employees with applying for waiver of premium with the previous carrier.
Class Change Effective Date
❑ Date of change ❑ First of the month following change ❑ January 1 ❑ Anniversary Date • Not Applicable
❑ Other:
Earnings Change Effective Date Date an employee's amount of insurance resulting from a change in the Employee's earnings will
take effect.
• Date of change ❑ First of the month following change ❑ January 1 ❑ Anniversary Date ❑ Not Applicable
❑ Other:
Age band changes
❑ Date of change ❑ First of the month following change ■ January 1 ❑ Anniversary Date ❑ Not Applicable
❑ Other:
Benefit Reduction Effective Date
❑ Date of change ❑ First of the month following change • January 1 ❑ Anniversary Date ❑ Not Applicable
❑ Other:
Continuation of Insurance Allows insurance to be continued if an employee is no longer in active service. Premium payment is
required. If applicable to your plan, please indicate maximum duration for each leave type listed.
FML Leave
■ The later of 12 weeks or the leave period required by state law (would include Military Caregiver Leave)
❑ Other:
Approved Unpaid Leave of Absence
❑ End of the Month in which the leave began (standard ) ❑ End of the Month following the month the leave began
❑ None ❑ Days ❑ Weeks • Months 1
Layoff*
■ None (standard ) ❑ Days ❑ Weeks ❑ Months
❑ End of the Month in which the layoff began ❑ End of the Month following the month the layoff began
*These continuation options are not applicable to Disability Coverages.
If any other Leave Types apply to your plan, please define ( i .e . : Sabbatical, Military) and indicate maximum time frames in the space provided
below.
Page 2 of 11
LIFE AND ACCIDENT PLAN COVERAGE INFORMATION
Plan (s) Sold • Life • Accident ❑ Not Applicable
Beneficiary Maintenance ❑ Paper • Electronic (a separate agreement will be provided for signature) .
Do you possess a complete record, and copies of, existing beneficiary designations? • Yes ❑ No
Do you allow Employees to make election changes any time throughout the year? ❑ Yes ■ No ❑ Not Applicable
If yes, please advise if changes are allowed due to ■ Life Status Event ■ Annual enrollment period : Refer to Proposal
❑ Other
Medical Underwriting is required for an Employee if they are a late entrant.
Does this match your administrative practice? ■ Yes ❑ No ❑ Not Applicable
If No, what amount of Guaranteed Coverage is provided ?
If Domestic Partners are covered, does Cigna need to provide you with an affidavit? ■ Yes ❑ No ❑ Not Applicable
If No, please provide Cigna with the affidavit that will be utilized
Calculation of Spouse Premium is based on ■ Spouse Age ❑ Employee Age ❑ Not Applicable
Include financial dependency in definition of dependent child ? ❑ Yes ■ No ❑ Not Applicable
Rounding for Times Salary Plans - Salary is multiplied first then rounding occurs • Yes ❑ No ❑ Not Applicable
If No, please describe :
Rounding for Increment Units Plans ■ Rounding Up ❑ Rounding Down ❑ Nearest ❑ Not Applicable
Must Voluntary Accident amount match the Voluntary Life Election ? ❑ Yes ❑ No • Not Applicable
If Yes, Is it an independent election or automatic match ? ❑ Independent Election ❑ Automatic Match
DISABILITY PLAN COVERAGE INFORMATION
Disability Plan(s) Sold • Fully Insured STD ❑ Self Insured STD • Fully Insured LTD ❑ Self Insured LTD ❑ Not Applicable
Short Term Disability Plans) Only
Weekly disability benefits are based on the number of days in a normally scheduled work week. They will be prorated if payable for
any period less than a week. Do your employees work a 5 or 7 day work week? ❑ 5 Day Work Week • 7 Day Work Week
Your response impacts the daily benefit amount. Benefits will be prorated on a 5 or 7 day basis. If your hours of operation include
weekends or shift work schedules it is recommended that you select 7 day work week.
`Self axed Disability Plan(s) Only
Does the Maximuthl3Emrefit.2.eripd include the Benefit Waiting Period ? ❑ Yes ❑ No
Benefit Waiting Period is based on ndar Days ❑ Business Days
Advice to Pay Medical Expense Funding ❑ Cigna funds medics r nses
❑ Employer funds expenses through a Cigna angement
❑ Employer receives invoices from Cigna as medical expenses are
Statutory Coverage Information
Do you�ai mployees working in the statutory states listed below? ❑ Yes ❑ No
If Yes, please c the boxes below to indicate coverage type .
Is Cigna providing any statuto verages? ❑ Yes ❑ No
Your Cigna Sales Representative will g ate a separate quote if not already provided. We may also provide additional state
required application forms for policy issuance.
❑ California ❑ New York ❑ New Jersey ❑ Puerto Rico
(Please provide prior carrier DP 1 if available.)
Number of males Num f males
Number of females Number of fe .des
❑ Hawaii Hawaii DOL Number:
Number of males Number of females
Hawaii Address :
Page 3 of 11
CLAIMS, :re lOCTURE & ADMINISTRATIVE CLAIMS REPORTING - SECTION 3
Disability Claim Structure Set-Up
Is it necessary to provide claims reporting by department or division ? • Yes ❑ No
If Yes, list desired reporting location(s) below.
Note: Employees will be required to identify their location when reporting claim.
Reporting Location(s) (i. e., Hourly, Salary, Union, Non-Union, Location, Region, Sales, Manufacturing)
By department
Disability Claim Reporting Set-Up On-line Reporting access is provided for all Disability Coverage.
Primary Contact* will have full administrator access to reporting functions and ability to delegate access functions.
(Must be an Employee of the Company). Name an alternate Disability Administrator contact below, if needed .
*If Primary Administrator should be other than Primary Contact listed on Page 1, outline in Additional Notes. Include name, title,
phone and email.
DISABILITY ALTERNATE ADMINISTRATOR (Must be an Employee - can delegate access to other users and has full access to reporting
functions)
NAME ADDRESS/CITY STATE ZIP CODE
Patricia Russell 1150 O Street CO 80631
PHONE EMAIL
970-400-4230 prussell@Weldgov.com
A. Additional users to be set-up during implementation for online reporting access? ❑ Yes • No
If Yes, please provide list that includes Name, Address and Email.
B. Can these users access reports for all locations? • Yes ❑ No
If No, you must also specify applicable reporting locations by user.
C. Select day for posting of Weekly STD Status Reports • M ■ T ❑W ❑TH ❑ F
STD Closed claims will appear for 2 weeks.
D . LTD Reports will be posted on the first day of each month LTD Closed claims will appear for 2 months .
E . Employee Name appears on claim reports . Please select an additional identifier if needed .
■ Employee Social Security Number • Employee ID Number
F . Would you like access to new claim intake reports? C Yes ❑ No
G . Is there any other Company Name the Employee could use when reporting a claim ? ❑ Yes No
If Yes, please list the Company Names:
H . Please provide Employer contact for Eligibility Verification . • Primary Contact
■ Other contact name : Patricia Russell e-mail : prussell@Weldgov.com
I . Would you like to receive an email notification when new reports are posted ? C Yes ❑ No
J . In addition to having report access, would you like to be copied on claim decision letters ? ■ Yes ■ No
K. If Cigna Healthcare is your medical provider, should outreach letters be sent to Employees? I-I Yes ■ No
Please provide contact for Disability claim decision letters if other than Primary Contact identified on page 1.
NAME EMAIL
Brandi Crawford bcrawford@weldgov.com
ADDRESS CITY STATE ZIP CODE
1150 O Street Greeley CO 80631
Life Claim Structure Set-Up
Is it necessary to provide claims reporting by department or division ? ❑ Yes • No
If Yes, list desired reporting location(s) in Additional Notes .
Note: It will be important to note appropriate location when reporting claim.
Reporting Location(s) (i. e., Hourly, Salary, Union, Non-Union, Location, Region, Sales, Manufacturing)
Life and AD&D Claim Reporting Set-Up On-line Reporting access is provided for all Life and AD& D coverages.
Online Reporting access is provided for all Life and AD& D coverages. Primary Contact*will have full administrator access to reporting
functions and must be an Employee of the Company.
*If Administrator should be other than Primary Contact listed on Page 1, outline in Additional Notes. Include name, title, phone and
email. Note: Title is required for set-up of Life and AD& D Claim Reporting.
Page 4 of 11
DISABILITY PLANS - EMPLOYER CONTRIBUTION, TAX AND YEAR-END
REPORTING INFORMATION - SECTION 4
ANNUAL TAX INFORMATION FOR DISABILITY BENEFIT PLANS
NEW BUSINESS
Disability Tax Service Agreement - Schedule I
APPLICABLE UNTIL DECEMBER 31st OF THE YEAR IN WHICH THE FIRST POLICY YEAR ENDS
I . Exemption from Social Security, Medicare Taxes and Federal Income Taxes (check all that apply)
• Our disability plan is not exempt from either Social Security, Medicare or Federal Income taxes.
❑ Our disability plan is exempt from Social Security for the following reason :
❑ Religious Institution ❑ Other (Specify)
❑ Our disability plan is exempt from Medicare taxes for the following reason :
❑ Religious Institution ❑ Other (Specify)
❑ Our disability plan is exempt from Federal Income taxes for the following reason :
❑ Religious Institution ❑ Other (Specify)
❑ Our disability plan is provided through
❑ Union ❑ an association; no employer is a party to the plan, and no employer contributes to plan costs.
II . Taxable and Nontaxable Percentages
Under Internal Revenue Code Section 105(a ), and IRS Regulations § 1 . 105-1(c) ( 1) and § 1 . 105-1 (d )(2), whether a disability benefit paid to an
employee is subject to income tax depends on the extent to which premium contributions were made by the employer, or by employees,
on a pre-tax basis.
For partially contributory plans, this determination is to be made based on the total cost paid on a pre-tax basis for the three policy years
ending on or before the start of the calendar year in which the employee becomes disabled . Example : For claims incurred in 2015,
premiums for the last three policy years ending on or before 12/31/2014 are taken into account.
Where a plan provides for two or more levels of employee contribution (e.g. core/buy-up plans), this determination is made separately for
each class or employee type . For a buy-up plan where employee contributions are post-tax, this requires that employer-paid (core)
premiums be allocated among core-only and core/buy-up participants. (See IRS Letter Ruling 9709051 ) .
Please check which of the following is applicable . If your policy or plan contains more than one class or employee type with different
benefit or contribution structure, please identify in the space provided below.
• Non-Contributory Plan - This policy/plan is paid for entirely by the employer on a pre-tax basis. Taxable Percentage is 100%.
■ STD ■ LTD
LK 752223 (STD) LK 965458 ( LTD)
Payroll Deduction Plan - This policy/plan is paid for entirely by employees on a post-tax basis . Includes mandatory as well as
volun plans. Taxable Percentage is 0%.
❑ ST LTD
❑ "Gross-Up" Plan - This policy/plan is paid for entirely by the employer; the employer cost is reported to employees on Form W-
2 ( IRS Letter Ruling 9708018) . Taxable Percentage is 0% .
❑ STD ❑ LTD
❑ Section 125 Plan - This policy/plan is paid for entirely by employees on a pre-tax basis. Taxable Percentage is 100% .
❑ STD ❑ LTD
❑ STD Partially Contributory Plan - This policy/plan is paid for partially by employees on a post-tax basis. The Taxable Percentage
during (year) is %. The Nontaxable Percentage during (year) is %. (Must total 100%.) (See attached worksheet.)
❑ LTD Partially Contributory Plan - This policy/plan is paid for partially by employees on a post-tax basis. The Taxable Percentage
during (year) is % . The Nontaxable Percentage during (year) is %. (Must total 100%.) (See attached worksheet.)
❑ STD Core/Buy-Up Plan - Core premium is paid by the employer on a pre-tax basis. The Taxab ercentage for core only
participants is 100%.
❑ Employees pay buy-up premium on a pre-tax basis. Taxable Percentage for buy-up participants is 100%.
❑ Employees pay buy-up premium on a post-tax basis. Taxable Percentage for buy-up participants during (year)
is %. The Nontaxable Percentage during (year) is %. (Must total 100%.)
(See attached worksheet.)
Page 5 of 11
DISABILITY PLANS - EMPLOYER CONTRIBUTION, TAX AND YEAR-END
REPORTING INFORMATION - SECTION 4 (Continued)
D. Tar le and Nontaxable Percentages (Continued)
❑ LTD Co -Up Plan - Core premium is paid by the employer on a pre-tax basis. The Taxable Percentage for core only
participants is 100%.
❑ Employees pay buy-up premiu re-tax basis. Taxable Percentage for buy-up participants is 100%.
❑ Employees pay buy-up premium on a pos - sis . Taxable Percentage for buy-up participants during (year) is % .
The Nontaxable Percentage during (year) is o. st total 100%.) (See attached worksheet.)
❑ Tax Choice ( Rev. Rul . 2004-55) Plan - Participants can choose whether all con 'ons (employer or employee) are paid on a
pre-tax basis or a post-tax basis. We will, at time of claim, notify the insurance company whe e claimant had elected pre-tax
or post-tax contributions prior to the start of the year.
❑ STD ❑ LTD
III . Service Level Requested
• Preparation of Form W-2 only
❑ Self Insured STD ❑ Self Insured LTD ■ Fully Insured STD ❑ Fully Insured LTD
LK 752223 (STD)
■ Preparation of Form W-2 with Employer FICA depositing service
( If not previously confirmed selecting this option may require a rate view)
❑ Self Insured STD ❑ Self Insured LTD ❑ Fully Insured STD ■ Fully Insured LTD
LK 965458 (LTD)
❑ No tax services (Annual payment report provid -2 )
❑ Self Insured STD ❑ Self Insured LTD ❑ Fully Insured STD ❑ Fully Insured LTD
If W2 services are selected, please review the attached Disability Tax Service Agreement for complete disclosure of terms and conditions.
Form W-2 will be mailed to Employees home address unless otherwise specified.
1VTt ' of Self-Insured Benefits ( Does not apply to "advice to pay")
❑ All benefits pro ' u h the plan are insured ( no self-insured benefits are provided ) .
❑ Self-insured benefits are funde rust which bears an insurance risk ( may include employee contributions) .
❑ Self-insured benefits are NOT funded through a trus ars an insurance risk (e.g. the benefits are funded with employer
general assets) . ■ Mandatory FIT Withholding ❑ W-4 Based Withhol ing
V. Addresses for Tax Reports and Remittance
Tax reports should be sent to the following address :
Attention : Staci Datteri-Frey
Mailing Address: 1150 O Street Greeley, CO 80631
Remittances of withheld taxes should be sent to the following address* :
Attention : Staci Datteri-Frey
Mailing Address : 1150 O Street Greeley, CO 80631
*Applies to any self-insured plan, unless (1) the plan is funded through a trust which bears an insurance risk, or (2) Form 2678 has been
filed with and accepted by the Internal Revenue Service.
If any information provided on this form changes before the next year's annual update,
please notify your account manager.
Page 6 of 11
LIFE ASSISTANCE PROGRAM INFORMATION - SECTION 5
Life Assi °asc or Employee Assistance Program Sold ❑ Yes (If Yes, select type) • No
❑ Life Assistance Pro " LAP" ❑ 3 visit clinical sessions ❑ 5 visit clinical sessions
❑ Full Employee Assistance Progra " " ( includes up to 3 clinical sessions and Employer Service hours of 10 per 1,000 employees)
Until the LAP or EAP Agreement is finalized and execute , rvices provided by Cigna Behavioral Health, Inc. shall be in accordance
with the terms of Cigna Behavioral's standard LAP or EAP Agreemen . lover shall reimburse Cigna Group Insurance for Cigna
Behavioral LAP or EAP services through the agreed upon combined product an or EAP services rate .
The parties agree to negotiate in good faith the terms of the definitive LAP or EAP Agree and to execute such Agreements as
soon as practicable. Once the LAP or EAP Agreement is finalized, that agreement will supersede thi ication and will apply
retroactively to the effective date of Cigna Behavioral's administration of the LAP or EAP services.
By signing this Application, Employer indicates acknowledgement of and agreement with this arrangement.
CIGNA ABSENCE ASSISTANT - SECTION 6
t. r:. ,a�st�wr�dti;;.r.L..
Cigna Affse sistant Sold ❑ Yes • No
Cigna Absence Assistan reement must be executed prior to the Absence Assistant Orientation Meeting. Upon receipt of a
signed agreement, Cigna will schedule an ' tion meeting to provide the client with Cigna Absence Assistant Resource Guide for
Managing FMLA and ADA. The client will also be given ac D GuidelinesT"' Leave of Absence Advisor, a web-based compliance
database of federal and state job-protect leave laws and FML & ADA 1 rk training tutorial for managers and supervisors.
Once the orientation process is completed, the client can refer FMLA leave or ADA acco ' n case requests for consultative
guidance and recommendation .
ERISA PLAN INFORMATION - SECTION 7
Please refer to Cigna 's ERISA Coverage Worksheet to determine whether a policy is issued in conjunction with ERISA. In general, any
group insurance policy issued to an employer to insure employees, or to a labor union to insure union members, is subject to ERISA.
Does your Company file annual ERISA reports? ❑ Yes • No If Yes, please complete the following information .
ERISA PLAN NAME
ERISA PHONE NUMBER
ERISA PLAN NUMBER(S)
■ Life ❑ Accident ❑ STD ❑ LTD
PLAN OF BENEFITS IS ❑ lover ❑ Employer ❑ Employer ❑ Employer
FINANCED BY ❑ Employ ❑ Employees ❑ Employees ❑ Employees
❑ Employer & ❑ Employer & ❑ Employer & ❑ Employer &
Employees Employees Employees Employees
PLAN YEAR ENDS ❑ Calendar Year ❑ Policy Year (Anniversa Fiscal Year (provide fiscal year date)
PLAN ADMINISTRATOR
❑ Employer ❑ Other — if other, please provide
Name
Address
AGENT FOR LEGAL PROCESS
❑ Same as Plan Administration ❑ Other — If other, please provide
Page 7 of 11
PREMIUM AND BILLING INFORMATION - SECTION 8
Premium Administration
On-line Premium Reporting System • Yes ❑ Other
a. Please list each desired billing locations(s)
b. Will we receive payment from each Billing Location ? ❑ Yes • No, assumes one payment will be remitted from the
primary billing contact.
Billing Contact Name : Barbara Connolly Phone : 970-400-4445 E- mail : bconnolly@co.weld.co.us
Billing Contact Name : Vicki Mau Phone : 970-400-4442 E- mail : vmau@co.weld.co.us
Billing Contact Name : Patricia Russell Phone : 970-400-4230 E- mail : prussell@weldgov.com
Billing Contact Name : Staci Datteri-Frey Phone : 970-400-4235 E- mail : sfrey@weldgov.com
VOLUNTARY ENROLLMENT INFORMATION - SECTION 9
Enrollment Event • Yes Event Start Date 10/1/17 End Date* 11/30/17 No ❑
* Please indicate the last day the employee is allowed to sign the enrollment application .
Date Enrollment Materials needed 9/18/17 Printed Brochures required ? ❑ Yes • No
If Yes, please provide distribution instructions including physical address,
contact name, phone number and quantity needed by class on a separate
Combine Enrollment Brochures for Voluntary Life and Voluntary Accident Coverages? ■ Yes ❑ No ❑ Not applicable
Medical Underwriting Status Report Format ❑ PDF • Excel
Please note Medical Underwriting Status Report will be sent to Primary Contact unless otherwise indicated below.
NAME EMAIL
ADDRESS CITY STATE ZIP CODE
Page 8 of 11
PRODUCER/GENERAL AGENT COMMISSION INFORMATION - SECTION 10
Writing Agent currently appointed with Cigna Group Insurance in group situs state? • Yes ❑ No
If applicable, our Central Licensing Department will provide appointment package for completion.
PRODUCER/GENERAL AGENT COMPANY NAME COMMISSION TAX ID#
Shirazi Benefits 20-4864708
PRODUCER NAME (WRITING AGENT) TITLE
Masoud Shirazi
STREET ADDRESS CITY STATE ZIP CODE PHONE EMAIL
8205 W. 20th Street Greeley CO 80634 970-381-3039 mshirazi@shirazibenefits.com
LICENSING CONTACT NAME AT PRODUCER/GENERAL AGENT OFFICE PHONE EMAIL
Michael Shirazi 970-381-3039 Michael.Shirazi@shirazibenefits.com
DAY TO DAY PRODUCER CONTACT NAME PHONE EMAIL
Michael Shirazi 970-381-3039 Michael.Shirazi@shirazibenefits.com
IS PRODUCER A GENERAL AGENT? ❑ Yes ■ No
SUB-PRODUCER COMPANY/CONTACT NAME PHONE PHONE EXT.
EMAIL ADDRESS CITY STATE ZIP CODE
COMMISSION PAID TO Individual ■ Corporation ❑ No Commission Paid
• Life ■ Accident ■ STD ■ LTD
❑ Standard Blanket ❑ Standard Blanket ❑ Standard Blanket ❑ Standard Blanket
Commission Commission Commission Commission
❑ Case Specific ■ Case Specific • Case Specific • Case Specific
Commission 11 % Commission 11 % Commission 11 % Commission 11 %
Utilize this space to identify any other commission arrangements not specified above .
Producer receives additional 2% service fee
If Split Commission complete Second Producer Information below.
CND PRODUCER INFORMATION
Wri 0.g Agent currently appointed with Cigna Group Insurance in group situs state? ❑ Yes ❑ No
SECOND PRODUCER COMPANY NAME COMMISSION TAX ID#
SECOND PRODUCER NAME (WRITING AGENT) TITLE
STREET ADDRESS CITY STATE ZIP CODE PHONE EMAIL
LICENSING CONTACT NAME AT SECOND PRODU OFFICE PHONE EMAIL
DAY TO DAY SECOND PRODUCER CONTACT NAME PHONE EMAIL
COMMISSION PAID TO Individual ❑ Corporation ❑ No Commission Paid
❑ Life ❑ Accident ❑ STD ❑ LTD
❑ Standard Blanket ❑ Standard Blanket ❑ St- and Blanket ❑ Standard Blanket
Commission Commission Commi ' n Commission
❑ Case Specific ❑ Case Specific ❑ Case Specific ❑ Case Specific
Commission % Commission % Commission % Commission %
If more space is needed for additional contact information, please attach on eparate page.
EXCHANGE SERVICE PROVIDER ❑ Yes ❑ No
Exchange Service Provider Fee ❑ Yes ❑ No
Exchange Service Provider
SERVICE FEE PAYABLE TO ❑ Individual ❑ Corporation
Life Accident STD LTD
Service Fee % Service Fee % Service Fee % Service Fee %
Page 9 of 11
EMPLOYER REPRESENTATIVE SIGNATURE
We acknowledge receipt of this Implementation Kit. We confirm the accuracy of the proposal from the insurance company named
above and hereby accept the terms and conditions of the proposal and any attachments or modifications made to the proposal.
We confirm the accuracy of the plan and coverage identification information contained in Section 2 and agree to the premium billing
information contained In Section 8. We hereby request the issuance of insurance policies on the basis of this coverage and premium
billing information.
If applicable, we authorize LINA Benefit Payments, Inc. to perform the tax-related services related to our disability benefits described
in Section 4. We confirm the appointment of our producer identified in Section 10 above and authorize payment of compensation as
described therein.
We confirm that benefit payments of $5,000 or more under non-disability policies will be credited to a Draft Account in the name of
the claimant or beneficiary with the Insurance company if not otherwise directed by us.
We acknowledge receipt of the Privacy Notice.
We understand that the following insurance policies are to be issued to the Group Insurance Trust for Employers in the
PUBLIC ADMINISTRATION 9111-9721 9111
Industry SIC Code
TRUST ISSUED POLICY TYPE : Life II Accident
We hereby adopt the above-named trust as co-settlor and subscribe to that trust for the purpose of participation in these policies, which shall only
cover our eligible employees, and, if applicable, retirees and dependents. We confirm the appointment of Wilmington Trust Company as Trustee,
and of Life Insurance Company of North America ("LINA") as trust administrator. We appoint LINA, in its capacity as trust administrator, to represent
us in dealings with the Trustee related to the insurance trust. We understand that, in the event the policy(ies) are terminated for any reason, we will
cease to be a participant in the insurance trust. We understand that no benefits are provided by the trust other than the benefits described in the
insurance policy(ies).
Julie A . Cozad , Chair , Board of
Weld County Commissioners
plitteet;
Authorized Employer Representative Authorized Employer Repr n ive
(please print name here) itpieo e sign name he )
OCT 0 4 2&17
Date 10/04/2017
TO BE COMPLETED UPON RECEIPT OF COMPLETED AND SIGNED DOCUMENT
Assigned Policy Number(s)
FLX 968032 OK 969517 LK 752223 LK 965458
B & V Life B & V AD&D STD LTD
. ,'044:
Cigna
066 3 5 �
Page 10 of 11
ADDITIONAL NOTES
Annual Enrollment period is the month of October and November each year.
Termination of Benefits :
1 ) the date employment terminates for Short Term Disability Income and Long Term Disability Income
Insurance
2 ) last day of the month in which employment terminates for Employee Basic Life, Employee Basic Accidental
Death and Dismemberment and Employee Optional Life Insurance .
Continuation of Insurance - continued from page 2
1 ) up to 3 months of the Employee ' s paid vacation .
2 ) For Life and Accidental Death and Dismemberment Insurance - up to 12 months for Injury or Sickness
10100 Board of County Commissioners 10150 Public Information 10200 County Attorney
10400 Clerk to the Board 11100 Recording 1200 Elections and Registration
11300 Motor Vehicle 12100 Treasurer 13100 Assessor
14100 County Council 15100 District Attorney 15200 Juvenile Diversion
15300 Victim Assistance 15400 White Collar Crime 15500 DUI Intern
15600 MYAT Probation 16100 Finance and Administration 16200 Accounting
16300 Purchasing 16400 Human Resources 16500 Transportation
17100 Planning Services 17200 Buildings and Grounds 17300 Information Services
17350 GIS 17400 Phone Services 17600 Copy, Supply and Mail
21100 Administration Patrol 21110 Administration Detention 21120 Professional Std
21130 Civil 21140 Support Services 21200 Patrol
21205 Investigations 21210 Contract Services 21220 Municipal Contract Services
21230 Ordinance Enforcement 21240 Code Enforcement 21260 Regional Lab
21300 Victim Advocates 21410 Drug Task Force 22100 Communications
22400 Public Safety IT 23100 Paramedic Services 23200 Coroner/Medical Examiner
24100 Justice Services 24125 Work Release 24150 Adult Diversion
24200 Community Corrections 24410 Inmate Services 24415 Security
24420 Courts and Transportation 24425 Work Release 25100 Building Inspections
26100 Weed Control 26200 Office of Emergency Management
30100 W Administration 31100 Engineering 32100 PW Trucking
32200 PW Motor Grader 32300 PW Bridge Division 32400 Maintenance Support
32500 PW Seasonal 32600 PW Mining 32700 Pavement Management
41100 Public Health Administration 41210 Public Health Communication 41300 Public Health Services
41400 Environmental Health 41500 Public Health Preparedness
41600 Public Health Clinical Service 42110 Public Welfare Administration 42115 Other Programs
42140 SocSer FRAUD 42200 IV- D Administration 42365 TANF
42375 Child Care 42410 Child Welfare 42610 SS Administration
50100 Missile Site Park 53100 Airport General Operations
60100 Human Services Administration 60105 Employment Services 60110 Area Agency on Aging
60115 Transportation-- Mini Bus 60120 Family Educational Network WC 60125 Client Payroll Pool
74400 Federal Mineral Lease 90100 Retirement Excess Benefit 90160 Bright Futures
90400 Interagency Oversight Group 96100 CSU Cooperative Extension 96200 Weld County Fair
96300 Fleet Services 96400 Veterans Service
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