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Home My WebLink About20243362.tiffRESOLUTION RE: APPROVE EXCESS RISK SINGLE EMPLOYER APPLICATION AND ADMINISTRATION AGREEMENT FOR STOP LOSS INSURANCE POLICY, AND AUTHORIZE CHAIR TO SIGN - RELIASTAR LIFE INSURANCE COMPANY, DBA VOYA FINANCIAL WHEREAS, the Board of County Commissioners of Weld County, Colorado, pursuant to Colorado statute and the Weld County Home Rule Charter, is vested with the authority of administering the affairs of Weld County, Colorado, and WHEREAS, the Board has been presented with an Excess Risk Single Employer Application and an Administration Agreement for the Stop Loss Insurance Policy between the County of Weld, State of Colorado, by and through the Board of County Commissioners of Weld County, on behalf of the Department of Human Resources, and ReliaStar Life Insurance Company, dba VOYA Financial, commencing January 1, 2025, with further terms and conditions being as stated in said application and agreement, and WHEREAS, after review, the Board deems it advisable to approve said application and agreement, copies of which are attached hereto and incorporated herein by reference. NOW, THEREFORE, BE IT RESOLVED by the Board of County Commissioners of Weld County, Colorado, that the Excess Risk Single Employer Application and the Administration Agreement for the Stop Loss Insurance Policy between the County of Weld, State of Colorado, by and through the Board of County Commissioners of Weld County, on behalf of the Department of Human Resources, and ReliaStar Life Insurance Company, dba VOYA Financial, be, and hereby are, approved. BE IT FURTHER RESOLVED by the Board that the Chair be, and hereby is, authorized to sign said application and agreement. cc •, pECss/AD/AP/I3p) 0 I /fig//5 2024-3362 PE0036 EXCESS RISK SINGLE EMPLOYER APPLICATION AND ADMINISTRATION AGREEMENT FOR STOP LOSS INSURANCE POLICY - RELIASTAR LIFE INSURANCE COMPANY, DBA VOYA FINANCIAL PAGE 2 The above and foregoing Resolution was, on motion duly made and seconded, adopted by the following vote on the 23rd day of December, A.D., 2024. BOARD OF COUNTY COMMISSIONERS WELD CO OLORA ATTEST: ditAmj Gl ydm% Weld County Clerk to the Board BY: oc.iAlt&L Deputy Clerk to the Board APP aVE y • rney Date of signature: Kevin D. Ross, Chair EXCUSED Perry L. Buck, Pro-Tem Mike reeman ott K. James CUSED on Saine 2024-3362 PE0036 Conkvckc* tDW93dl BOARD OF COUNTY COMMISSIONERS PASS -AROUND REVIEW PASS -AROUND TITLE: Voya Stop Loss Carrier DEPARTMENT: HR DATE:12/3/2024 PERSON REQUESTING: Allison Palmer & Jill Scott Brief description of the problem/issue: The County's current stop loss carrier, Aetna, has been provi ding coverage for high -cost claims. Hub went to market for us and Aetna did not want to match after an extensive review of the stop loss market, it has been determined that switching to Voya would provide substantial savings to the County. This switch is expected to save the County $450,000 annually. What options exist for the Board? Stay with Aetna: Continue with the existing stop loss coverage, which would result in higher premiums with no savings. Switch to Voya: Transition to Voya as the new stop loss carrier, saving the County $450,000 annually. This option comes with the requirement to cover high claims upfront while awaiting reimbursement from Voya, which could temporarily increase cash flow requirements. Consequences: Stay with Aetna: No immediate change, but continued high p -emiums will strain the County's benefits budget. Switch to Voya: While the County will save $450,000 annually, there will be a temporary cash flow challenge as high claims need to be paid upfront, before reimbursement from Voya is received. However, the CFO has confirmed that the County has sufficient cash reserves to cover these claims in the interim. Costs (Current Fiscal Year / Ongoing or Subsequent Fiscal Years): The switch to Voya involves additional administrative burden as the benefits team will need to manage the high claims. The main financial benefit, however, is the substantial annual savings of $450,000. Recommendation: Given the substantial savings of $450,000, it is recommended that the Board approve the switch to Voya as the new stop loss carrier. Although the trarsition will require some additional administrative work and upfront cash flow management, the long-term savings will far outweigh these temporary inconveniences. The CFO has confirmed the County's cash reserves are adequate to cover the gap, making this a financially sound decision for the future. Support Recommendation Schedule Place on BOCC Agenda Work Session Other/Comments: Perry L. Buck, Pro-Tem Mike Freeman Scott K. James Kevin D. Ross , Chair Lori Saine "J% Gmcul \kOit tmed Una ��nail wa trust, 2024-3362 17173 P50c3w Karla Ford From: Sent: To: Cc: Subject: Approve Kevin Ross Kevin Ross Tuesday, December 3, 2O24 6:34 PM Perry Buck; Karla Ford Commissioners Re: Please Reply - HR Pass -around Voya From: Perry Buck <pbuck@weld.gov> Sent: Tuesday, December 3, 2O24 5:O6:45 PM To: Karla Ford <kford@weld.gov> Cc: Commissioners <COMMISSIONERS@co.weld.co.us> Subject: Re: Please Reply - HR Pass -around Voya Approve Thank you Sent from my iPhone On Dec 3, 2O24, at 3:O4 PM, Karla Ford <kford@weld.gov>wrote: Please advise if you support recommendation and to have department place on the agenda. Karla Ford i. Office Manager, Board of Weld County Commissioners 1150 O Street, P.O. Box 758, Greeley, Colorado 80632 :: 970.336-7204 :: kford weld.gov :: www.weldgov,com :: **Please note my working hours are Monday -Thursday 7:00a.m.-4:00p.m.** <i mage002. jpg> Confidentiality Notice: This electronic transmission and any attached documents or other writings ore intended only for the person or entity to which it is addressed and may contain information that is privileged, confidential or otherwise protected from disclosure. if you have received this communication in error, please immediately notify sender by return e-mail and destroy the communication. Any disclosure, copying, distribution or the taking of any action concerning the contents of this communication or any attachments by anyone other than the named recipient is strictly prohibited. From: Allison Palmer <apalmer@weld.gov> Sent: Tuesday, December 3, 2024 3:O3 PM To: Karla Ford <kford@weld.gov> Cc: Jill Scott <jscott@weld.gov>; Cheryl Pattelli <cpattelli@weld.gov> Subject: Pass -around Voya Karla Ford From: Sent: To: Cc: Subject: Mike Freeman Tuesday, December 3, 2024 3:09 PM Karla Ford Commissioners Re: Please Reply - HR Pass-arounc Voya Approve Sent from my iPhone On Dec 3, 2024, at 3:O4 PM, Karla Ford <kford@weld.gov>wrote: Please advise if you support recommendation and to have department place on the agenda. Karla Ford X Office Manager, Board of Weld County Commissioners 1150 0 Street, P.O. Box 758, Greeley, Colorado 80632 :: 970.336-7204 :: kford a(�.weld.gov :: www.weldgov.com :: **Please note my working hours are Monday -Thursday 7:00a.m.-4:09p.m.** <image002.jpg> Confidentiality Notice: This electronic transmission and any attached documents or other writings are intended only for the person or entity to which it is addressed and may contain information that is privileged, confidential or otherwise protected from disclosure. If you have received this communication in error, please immediately notify sender by return e-mail and destroy the communication. Any disclosure, copying, distribution or the toking of any oction concerning the contents of this communication or any attachments by anyone other than the named recipient is strictly prohibited. From: Allison Palmer <apaImer@weld.gov> Sent: Tuesday, December 3, 2024 3:03 PM To: Karla Ford <kford@weld.gov> Cc: Jill Scott <jscott@weld.gov>; Cheryl Pattelli <cpattelli@weld.gov> Subject: Pass -around Voya Hi Karla, Attached is the pass -around for Voya. Thanks, Karla Ford From: Sent: To: Cc: Subject: Approve - thanks ** Sent from my iPhone ** Scott James Tuesday, December 3, 2024 3:09 PM Karla Ford Commissioners Re: Please Reply - HR Pass -around Voya Scott K. James Weld County Commissioner, District 2 1150 O Street, P.O. Box 758, Greeley, Colorado 80632 970.336.7204 (Office) 970.381.7496 (Cell) Confidentiality Notice: This electronic transmission and any attached documents or other writings are intended only for the person or entity to which it is addressed and may contain information that is privileged, confidential or otherwise protected from disclosure. If you have received this communication in error, please immediately notify sender by return e-mail and destroy the communication. Any disclosure, copying, distribution or the taking of any action concerning the contents of this communication or any attachments by anyone other than the named recipient is strictly prohibited. On Dec 3, 2024, at 3:04 PM, Karla Ford <kford@weld.gov>wrote: Please advise if you support recommendation and to have department place on the agenda. Karla Ford g Office Manager, Board of Weld County Commissioners 1150 0 Street, P.O. Box 758, Greeley, Colorado 80632 :: 970.336-7204 :: kford weld.gov :: www.weldgov.com :: **Please note my working hours are Monday -Thursday 7:00a.m.-4:00p.m.** <image002. jpg> Confidentiality Notice: This electronic transmission and any attached documents or other writings are intended only for the person or entity to which it Is addressed and may contain information that is privileged, confidential or otherwise protected from disclosure. If you hove received this communication in error, please immediately notify sender by return e-mail and destroy the communication. Any disclosure, copying, distribution or the taking of any action concerning the contents of this communication or any attachments by anyone other than the named recipient is strictly prohibited. 1 Karla Ford From: Sent: To: Subject: yes Lori Saine Weld County Commissioner, District 3 1150 O Street PO Box 758 Greeley CO 80632 Phone: 970-400-4205 Fax: 970-336-7233 Email: Isaine@weldgov.com Website: www.co.weld.co.us In God We Trust Lori Saine Wednesday, December 4, 2024 9:40 AM Karla Ford RE: Please Reply - HR Pass -around Voya Confidentiality Notice: This electronic transmission and any attached documents or other writings are intended only for the person or entity to which it is addressed and may contain information that is privileged, confidential or otherwise protected from disclosure. If you have received this communication in error, please immediately notify sender by return e-mail and destroy the communication. Any disclosure, copying, distribution or the taking of any action concerning the contents of this communication or any attachments by anyone other than the named recipient is strictly prohibited. From: Karla Ford <kford@weld.gov> Sent: Tuesday, December 3, 2024 3:05 PM To: Commissioners <COMMISSIONERS@co.weld.co.us> Subject: Please Reply - HR Pass -around Voya Importance: High Please advise if you support recommendation and to have department place on the agenda. Karla Ford X 1 EXCESS RISK SINGLE EMPLOYER APPLICATION (CO) ReliaStar Life Insurance Company ("ReliaStar Life") Home Office: Minneapolis, Minnesota 55440 Plan Sponsor hereby applies for the Excess Risk Policy. PLAN INFORMATION Name of Plan Sponsor (exact legal name) Address (number and street) City ■ Greeley Corporation ■ Weld County Government 1150 O Street State CO Zip 80631 Partnership ■ Sole Proprietorship 2 Other. Specify: Government Nature of Plan Sponsor's Business Executive Offices Are subsidiaries, affiliates or other associated entities to be included? If "Yes," give Names. Relationship to Plan Sponsor ■ Yes 14 No SIC Code 9199 Please provide the number of individuals covered as noted below: Eligible Individuals Enrolled Individuals Individuals Covered Elsewhere The initial Contract Period is from Covered Persons Only 1,501 Covered Persons Only Covered Persons Only January 1, 2025 Covered Persons with Dependents 1,501 Covered Persons with Dependents through Covered Persons with Dependents December 31, 2025 CLAIM ADMINISTRATOR INFORMATION (Claim Administrator for coverages checked below for the Employee Benefit Plan) Name of Claim Administrator (exact legal name of entity) Aetna, CVS Caremark (Rx) Address (number and street) N/A City N/A State N/A Zip N/A Claim Administrator must be approved by ReliaStar Life prior to acceptance of this Application INDIVIDUAL EXCESS RISK Individual Excess Risk: lvi Yes Benefits To Be Covered: M. Medical Initial Coverage Period: Incurred and Paid in 12 months Incurred in 15 months and Paid in 12 months Paid in 12 months Other ■ ■ ■ ■ ■ No Q Other (Please specify) Prescription Drugs ■ Incurred in 12 months and Paid in 15 months [21 Incurred in 24 months and Paid in 12 months Individual Excess Risk Deductible S 350,000 per Individual Individuals subject to the Individual Adjusted Deductible as identified in the disclosure process N/A Claims for Individuals subect to the Individual Adjusted Deductible that exceed the Individual Excess Risk Deductible amount are excluded under any Aggregate Excess Risk Insurance. Benefit percentage 100% R L -SL -APP -2013 -CO Page 1 of 3 - Incomplete without all pages. Order #166285 CO 05/01/2014 INDIVIDUAL EXCESS RISK (Continued) Maximum Individual Benefit: Individual Excess Risk Lifetime Maximum: $ Unlimited Other Optional Endorsements: ■ ■ ■ ■ Q Q ■ Individual Excess Risk Annual Maximum: $ Individual Terminal Liability ■ 3 months ■ 6 months Individual Advanced Funding Individual Step -Down Deductible Individual Gapless Renewal (Only available for 12/15 or 12/18) Aggregating Individual Deductible: S (Individual Excess Risk must be elected) Plan Mirroring Coordination Renewal Rate Cap Other: Unlimited AGGREGATE EXCESS RISK Aggregate Excess Risk: [J1 Yes ■ No Benefits To Be Covered: 111 Medical ■ Vision [JJ Prescription Drugs ■ Dental ■ Other (Specify) Initial Coverage Period: ■ ■ ■ ■ Incurred and Paid in 12 months Incurred in 15 months and Paid in 12 months Paid in 12 months Other ■ 5 Incurred in 12 months and Paid in 15 months Incurred in 24 months and Paid in 12 months Aggregate Adjustment Corridor: 120 cio Minimum Annual Aggregate Deductible: See Excess Risk Schedule ReliaStar Life's Limit of Liability: $ 1,000,000 per Coverage Period Optional Endorsements: Q ■ ■ ■ Plan Mirroring Coordination Monthly Aggregate Reimbursement Aggregate Terminal Liability Other ■ 3 months ■ 6 months (Individual Terminal Liability must also be elected) Are retirees covered? • Yes Q No Are retirees age 65 and over covered? • Yes RI No Attached to and incorporated in this Application is a copy of the Employee Benefit Plan that relates to the Excess Risk Policy being applied for. The Producer/Agent of Record (provided he/she is duly licensed as required by law) is: Stealth Partner Group This insurance is to be effective on January 1, 2025 at 12:01 a.m. Standard Time at the Plan Sponsor's place of business. provided that the first premium is paid in full and that the Disclosure Agreement and this Application are accepted by ReliaStar Life. An advance deposit of S N/A is attached. (The deposit is to equal the first premium.) The deposit will be applied toward payment of the premiums on the insurance requested if the application is accepted by ReliaStar Life. If not accepted, the deposit will be refunded to the Plan Sponsor Applicant. R L -SL -APP -2013-C O Page 2 of 3 — Incomplete without all pages. Order #166285 CO 05/01/2014 ACKNOWLEDGEMENT & SIGNATURES By signing this Application below, the Plan Sponsor Applicant represents that all statements, answers and information made above in this application and in the Disclosure Agreement are complete and true to the best of its knowledge and belief. Plan Sponsor Applicant further acknowledges and agrees (i) that such statements, answers and information in this Application and in the Disclosure Agreement, together with a copy of the Employee Benefit Plan and other information attached to this application or furnished to ReliaStar Life, are submitted by the Plan Sponsor Applicant as an inducement to, and will be relied upon by, ReliaStar Life, in underwriting this risk and determining whether to accept this application and issue the Excess Risk Policy being applied for; (ii) if such statements, answers and information is/are incomplete or untrue, and such incompleteness or falsity is material to the risk to be insured by ReliaStar Life, any policy issued by ReliaStar Life may be rescinded and/o- any benefits that might otherwise be payable thereunder may be denied; and (iii) the Plan Sponsor Applicant has fully read and understands this comp eted Application and the Disclosure Agreement. 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 with the Department of Regulatory Agencies. Plan Sponsor Applicant Name of Signer (Please print) By Kevin D. Ross Weld County Government J) ATTEST: By: Clerk to the Board Deputy Clerk to the Boa Title Date Signed Chair, Board of Weld County Commissioners DEC 2 3 2024 RL-SL-APP-2013-CO Page 3 of 3 — Incomplete without all pages. Order#166285 CO 05/01/2014 z oZy-33(02 DISCLOSURE AGREEMENT ReliaStar Life Insurance Company, Minneapolis, MN A member of the Voya® family of companies (the "Company") A. FINANCIAL Policy Effective Date January 01, 2025 Plan Sponsor Name Weld County Government INSTRUCTIONS FOR COMPLETION Please provide the information described in the Disclosure Reports Section below and then have an authorized representative of the Plan Sponsor submit the Disclosure Agreement. Prior to submitting this Disclosure Agreement and Disclosure Reports to the Company, please consult with your current Claim Administrator(s), Utilization Review Firm(s), Case Management and Pharmacy Benefits Manager(s) (collectively, "Claim Verdors"), and Plan Sponsor's Broker or other insurance advisor. The Disclosure Reports must be provided to the Company no earlier than 90 calendar days prior to the Policy's Effective Date or renewal date, as applicable. Please note the required monthly claim reporting provided on behalf of the Plan Sponsor to Company will suffice for renewal purposes. Should the Company require any additional information, it will notify the Plan Sponsor and/or its designated representative in writing no later tian 20 calendar days following receipt of the Disclosure Reports. Any firm quote is void unless accepted by the Plan Sponsor in writing within 30 days from the date quoted by the Company. DISCLOSURE REPORTS Plan Sponsor has provided the following reports or data (which include claimant name and primary ICD-10 diagnosis) on the following date(s): See reporting prev.ous y provided on 9/24/24 • Any individual with paid claims that has exceeded 50% of the stop loss deductible during the applicable current policy year (minimum 8 months, • Any individual with denied and/or pended claims that has exceeded $25,000 during the applicable current policy year (minimum of 8 months); • Any individual evaluated and/or listed for an organ, stem cell or bone marrow transplant; • Any individual, including claim amounts for that individual, who is or was in case management or whose condition or diagnosis would be referred to case management during the applicable current policy year (minimum 8 months) by your claims Administrator based upon the ICD-10 codes used by your Claims Administrator for referral to case management; • Any individual, including claim amounts for that individual, whose condition or diagnosis during the applicable current po icy year (minimum 8 months) is represented by any of the ICD-10 codes contained in the attached list. DISCLOSURE AGREEMENT The Plan Sponsor represents to the Company, to the best of its Knowledge and belief, and after making a diligent and good faith inquiry, that it has fully read and understands this Disclosure Agreement; and as of the date of submitting this Disclosure Agreement there are no known potential catastrophic claims other than those disclosed on the submitted Disclosure Reports. The Plan Sponsor understands and agrees that the Company will rely on this Disclosure Agreement and the attached Disclosure Reports to: (i) underwrite this risk, (ii) determine whether or not to issue (or renew) a Policy and (iii) If the Company agrees to issue or renew a Policy, determine the terms, conditions, limitations and rates of or for such Policy. The Plan Sponsor further understands and agrees that if there are any undisclosed claimants known to the plan sponsor that are material to the risk to be insured by the Company, any Policy issued or renewed by the Company may be rescinded, any benefits that might otherwise be payable thereunder may be denied, and/or the premium rates, deductibles, terms, conditions and limitations of the Policy may be revised by the Company; and the requirement to submit any required Disclosure Report may not be waived by the Company without a written representation by the Plan Sponsor that there are no reports or data with respect to any individual required to be included on any of the Disclosure Reports above. To be eligible for a claim of reimbursement under the Policy, the Plan Sponsor or the Claims Administrator must request payment and provide complete and accurate Proof of Loss, in the form and content acceptable to the Company, to support a claim within 180 days after the end of the Coverage Period of the Policy. R L -SL -DISC LOSE -2020 Page 1 of 2 Order #214800 07/01/2021 ICD-10 CODES FOR DISCLOSURE NOTIFICATION The following ICD-10 Codes for Disclosure Notification provide conditions or diagnosis which must be disclosed. Please list all Plan Participants who have been diagnosed with or treated for any of the Codes listed under the following categories during the current Benefit Period. Where a range of Codes is shown, any and all conditions or diagnosis within that range must be disclosed. A00 -B99 B17.1 -B17.11 COO -D49 COO -C14 C15 -C26 C30 -C39 C43 -C44 C50 -050 C51 -C68 C69 -C72 C81 -C96 D50 -D89 D57.1 D61.01 D66 D81.0 D82.1 D83.1 Infectious Diseases Hepatitis C Neoplasms Malignancies of oral cavity and pharynx Malignant neoplasm of digestive organs Malignant neoplasm of respiratory Melanoma Breast Malignancies Genitourir ary Malignancies Malignancies of Nervous System Leukemias, Lymphomas and Myelomas Hematologic Disorders Sickle Cell Anemia Aplastic Anemia Hemophil a/Hereditary Factor VIII Deficiency Severe Combined Immune Deficiency (SCID) DiGeorge Syndrome Immune Deficiency T Cells (AIDS) D84.1 Alpha 1-Antitrypsin E70 -E88 E75.22 E84.0 GOO -G99 G12.21 G61 0 G82.50 G91.1 100-199 127.0 142.0-142.9 146.9 160.9 Metabolic Disorders Gaucher's Disease Cystic Fibrosis Disease of the Nervous System Lou Gehrig's disease (ALS) Guillain-Barre Syndrome Quadriplegia Obstructive Hydrocephalus Disease of Circulatory System Primary Pulmonary Hypertension Cardiomyopathy Cardiac Arrest Subarachnoid Hemorrhage J00 -J99 Disease of Respiratory System J96.00 -J96.92 Respiratory Failure K00 -K95 Disease of Digestive System K70.0 -K74.69 Chronic Liver Disease K72.00 -K72.91 Liver Failure M86 Diseases of Musculoskeletal System and Connective Tissue M83 Osteomyelitis NO) -N99 Disease of Genitourinary System N13.1 -N18.9 Chronic Renal Failure 000-09A Pregnancy, Childbirth & Puerperium O30.10 --O30.109 Triplet Pregnancy O30.20 -O30.209 Quadruplet Pregnancy O60.00 --O60.14 Preterm Labor P00 -P96 Perinatal Conditions P07.00 -P07.36 Preterm Infant P22.0 Respiratory Distress Syndrome of Newborn QC 0-Q99 Q20 -O28 Q39.0 -Q39.4 QE19.7 SC 0-188 SC 6.0-S06.9 S12 -S14 SE8 TC7 T2 0-132 T79 T86 -Z94 T86.00 -T86.02 T86.00 -T86.09 T86.90 -T86.92 T86.90 -T89.99 Z94 Congenital Malformations Congenital Heart Diseases Tracheoesophageal Fistula Multiple Anomalies Injury, Poisoning and Trauma Brain Injuries Spinal Cord Injuries Amputations Multiple Trauma Injuries Burns Early Complications of Trauma Complications Peculiar to Certain Specified Conditions Graft vs. Host Disease Graft vs. Host Disease Complications of Transplants Complications of Transplants Transplants R L -SL -DISC LOSE -2020 Page 2 of 2 Order #214806 07/01/2021 ADMINISTRATION AGREEMENT ReliaStar Life Insurance Company, Minneapolis, MN ReliaStar Life Insurance Company of New York, Woodbury, NY Members of the Voya® family of companies (the "Company") A FINANCIAL Policyholder Name (the "Policyholder") Weld County Government Policy Effective Date 01/01/2025 Insurance Contracts. The Company issues insurance policies and certificates based on your application and our state approved products (the "Policies"). Our obligations are determined solely by the terms of the policies we issue. EXCESS RISK COVERAGE Claim Administration. Upon determination of a potential claim under the Policy, yoL will confirm employees' eligibility for coverage and provide required eligibility and claim documentation to the Company, either directly or through your health claim administrator. The Company shall be responsible for all claim reviews, determinations and payments under the Policy. Confidentiality. We will keep confidential all information provided to us by you or your health claims administrator in connection with the Policy, in compliance with applicable law. You authorize your health claims administrator, if any, to release to the Company information and data regarding claims paid to be used in connection with the Policy. GROUP ANNUAL TERM LIFE, PERSONAL ACCIDENT INSURANCE, DISABILITY, CRITICAL ILLNESS, ACCIDENT AND/OR HOSPITAL CONFINEMENT INDEMNITY COVERAGE Policy Administration. Your group policy will be "Self -Administered". This means tha: you or a third party that you engage will be responsible to maintain all enrollment, beneficiary, and billing records for the Policies (as applicable). The recores you keep must provide the ability for you and/or your employees to: • appropriately apply Policy limits and rules • know how much coverage the employee has at all times • provide the employee with the appropriate "Conversion" and/or "Portability" documentation (as applicable) • set up any payroll deductions correctly • pay premium to the insurance company with supporting documentation • file a claim The parties agree that the Policies will be self-administered by Policyholder and that :he insurance charges reflect that arrangement. Communications. All forms and other materials we provide to you must be presented to employees without alteration. Any benefit and eligibility descriptions you or your third party service provider communicates to employees must be consistent with the materials and guidelines we provide to you. We will work carefully with you to make corrections in the case of any inadvertent error in communications. However, you are responsible for any costs incurred in correcting errors caused by incorrect data you provide to employees or to Company, including incorrect benefit descriptions and eligibility determinations. Evidence of Insurability. If evidence of insurability is required in connection with En application for coverage under the terms of a Policy, you will apply the evidence of insurability rules appropriately, obtain the necessary forms from any applicant for such coverage and provide those forms to the Company. Claim Administration. Upon receipt of notice of a potential claim under a Policy, ycu will confirm employees' eligibility for coverage and provide required claim documentation at the Company's request. The Company shall be responsible for all claim reviews, determinations and payments. Certificates of Insurance and Summary Plan Description. If you request that WE provide Summary Plan Description(s) ("SPD") for distribution to ERISA plan participants, we will provide the SPD using our standard language and forma: unless otherwise directed by you. If we agree to electronically post certificates of insurance and/or SPDs for access by your employees, you are respc nsible for assuring that each covered employee is informed how the documents can be accessed and that each employee has access or otherwise receives a copy(ies) of these documents. Any legal advice as to the style, format, content or distribution of the SPD or distribution of the certificate of insurance must be provided by your legal counsel. We are unable to provide legal advice to your plan and assume no responsibility for meeting ERISA's disclosure requirements. Indemnity. Each Party to this Agreement shall be responsible for any liability, clain, loss, damage, or expenses, including without limitation, reasonable attorney fees, arising from its negligent acts or omissions in connection with its perfcrmance of this Agreement, or its failure to comply with the terms of this Agreement, as determinec by a court of competent jurisdiction. Nothing in this section shall be construed as an obligation of the Policyholder to defend, hold harmless, or indemnify any other party, entity, or individual, even for claims that are the result of negligent acts or omissions of the Policyholder. Self -Administered Page 1 of 2 - Incomplete witiout all pages. Order #173385 Weld County 11/21/2024 GENERAL ADMINISTRATION - ALL PRODUCTS: Record Keeping. You agree to maintain accurate books and records documenting the administration of the Policies, including employee demographics, eligibility records, dependent data, coverage amounts, enrollment history, payroll deductions, benefit elections and beneficiary designations (as applicable). Such records must be maintained for a period of seven (7) years following termination of the Policies to which they relate. Upon reasonable notice, we shall have the right to review, inspect and audit, at our expense, the books, records, data files or other information maintained by you or your vendor related to the Policies. Transmission of Data. You are responsible for the accuracy and security of data transmitted to us, including data transmitted by any third party service provider you engage to assist in administration of your benefit plans. Each party will establish and maintain (1) administrative, technical and physical safeguards against the destruction, loss or alteration of data, and (2) appropriate security measures to protect data, which measures are consistent with all state and federal regulations relating to personal information security, including, without limitation, the Gramm -Leach -Bliley Act. Premium payment. If you engage a third party to submit premium to us, we will not consider the premium paid until it is received in our Home Office. General terms. This Agreement will remain in effect during the duration of the Policy and will terminate automatically upon termination of all Policies. This Agreement may be amended only in writing signed by both parties. In the event of any conflict or inconsistency between the terms of this Agreement and the terms of any Policy, the terms of the Policy shall control. Governing law. This Agreement shall be governed in all respects, including validity, interpretation and effect, without regard to principles of conflict of laws, by the law of the state where the Policy is issued. Accepted and Agreed to: Policyholder Name (Please print.) Weld County Governme hIM Policyholder Authorized Signature Date DEC 2 3 2024 Print signer's name and title Kevin D. Ross, Chair, Weld County Board of Commissioners RELIASTAR LIFE INSURANCE COMPANY RELIASTAR LIFE INSURANCE COMPANY OF NEW YORK h1=0 Company Authorized Signature Print signer's name and title Mona Zielke, Vice President Date 11/21/2024 Self -Administered Page 2 of 2 - Incomplete without all pages. Order #173385 Weld County 11/21/2024 zoz4 33(o2 DIRECT DEPOSIT AUTHORIZATION FOR STOP LOSS CLAIM PAYMENTS ReliaStar Life Insurance Company, Minneapolis, MN ReliaStar Life Insurance Company of New York, Woodbury, NY Members of the Voya® family of companies (the "Company") Stop Loss Claims: 20 Washington Avenue South, Route 5310, Minneapolis, MN 55401 Email: stoploss@voya.com FINANCIAL Use this form for enrollment in direct deposit, cancellation of direct deposit or a change (e.g., the financial institution changed or the account number changed). Send a copy of this form to your Voya Client Representative and retain a copy for your records. Select one: [vi Enrollment ❑ Cancellation ❑ Change Plan Sponsor Name (Legal Entity) Weld County Government Address 1150 O Street Tax Identification Number (TIN) 84-0857486 City Greeley State CO zIP 80631 Contact Name (Provide the name of the person who should be contacted if this form is incomplete or requires additional information.) Jill Scott, Director of the Department of Human Resources Phone ( 970 ) 400-4230 Email address where Explanation of Reimbursement (EOR) should be sent. J scott@weld.gov BANK ACCOUNT INFORMATION A voided check for the account should accompany this form. A deposit ticket is not acceptable. If you cannot provide a voided check, enter the bank's routing number and the full account number in the appropriate fields. Your application cannot be processed without this information. Routing Number (9 digits) 1 0 2 0 0 0 0 7 6 Account Number Account Name (Plan Sponsor, group or business name as listed on the account.) Weld County Government Bank Name Wells Fargo Bank Account Type: VI Checking ❑ Savings Bank Address 2164 35th Avenue City Greeley Bank Phone ( 970 ) 336-6243 State CO ZIP 80634 AUTHORIZATION The Plan Sponsor grants authorization to the Company to initiate credit entries to the checking or savings account at the financial institution named above. This authority is to remain in full effect until the Company has received written notification of a change or cancellation of this authorization. Plan Sponsor Representative Name (Plea mt.) Ke D. Ross, Chair, Board of Weld County Commissioners hIIM Signature Date DEC 2 3 2024 Sample Check Routing Number (9 digits) \ Financial Institution MEMO 987654321 1234567890123 Not Negotiable 5678 Account Number Page 1 of 1 Order #164376 07/30/2018 lbL4r 3kQ Form W-9 (Rev. October 2018) Department of the Treasury Internal Revenue Service Request for Taxpayer Identification Number and Certification ► Go to www.i►s.gov/FormW9 for instructions and the latest information. Give Form to the requester. Do not Send to the IRS. a ° 6 � `o 1 d +._. �V to 31 1 Name (as shown on your income tax return). Name is required on this line; do not leave this line blank. ReliaStar Life Insurance Company 2 Business name/disregarded entity name, if different from above Voya Financial 3 Check appropriate box for federal tax classification of the person whose name is entered on line 1. Check only seven boxes. ❑ Individual/sole proprietor or M C Corporation ❑ S Corporation ❑ Partnership sin le -member LLC 9 ❑ Limited liability company. Enter the tax classification (C=C corporation, S=5 corporation, P=Partnership) ► Note: Check the appropriate box in the line above for the tax classification of the single -member owner. LLC if the LLC is classified as a single -member LLC that is disregarded from the owner unless the owner another LLC that is not disregarded from the owner for U.S. federal tax purposes. Othrwise, asinglemember is disregarded from the owner should check the appropriate box for the tax classification of its owner. ❑ Other (see instructions)► one of the following ❑ Trust/estate 4 Exemptions certain entities, instructions Exempt payee Exemption code of an, (Applies to accounts (codes apply only to not individuals; see on page 3): code (if any) 5 from FATCA reporting Do not check of the LLC is LLC that main ainedouKide the U.5.) 5 Address (number, street, and apt. or suite no.) See instructions. 20 Washington Ave South Requester's name and address (optional) 6 City, state, and ZIP code Minneapolis, MN 55401 7 List account numbers) here (optional) Taxpayer Identification Number (TIN) Enter your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoid backup withholding. For individuals, this is generally your social security number (SSN). However, for a resident alien, sole proprietor, or disregarded entity, see the instructions for Part I, later. For other entities, it is your employer identification number (EIN). If you do not have a number, see How to get TIN, later. Note: If the account is in more than one name, see the instructions for line 1. Also see What Name and Number To Give the Requester for guidelines on whose number to enter. inn Certification Under penalties of perjury, I certify that: 1. The number shown on this form is my correct taxpayer identification number (or I am waiting fora number to be issued to me); and 2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding; and 3. I am a U.S. citizen or other U.S. person (defined below); and 4. The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct. Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the instructions for Part II, later. Social security number or Employer identification number 4 0 4 5 4 0 Sign Here Signature of US. person ► Date ► 4/13/2022 General Instructions Section references are to the Internal Revenue Code unless otherwise noted. Future developments. For the latest information about developments related to Form W-9 and its instructions, such as legislation enacted after they were published, go to www.irs.gov/FormW9. Purpose of Form An individual or entity (Form W-9 requester) who is required to file an information return with the IRS must obtain your correct taxpayer identification number (TIN) which maybe your social security number (SSN), individual taxpayer identification number (ITIN), adoption taxpayer identification number (ATIN), or employer identification number (EIN), to report on an information return the amount paid to you, or other amount reportable on an information return. Examples of information returns include, but are not limited to, the following. • Form 1099-INT (interest earned or paid) • Form 1099-DIV (dividends, including those from stocks or mutual funds) • Form 1099-MISC (various types of income, prizes, awards, or gross proceeds) • Form 1099-B (stock or mutual fund sales and certain other transactions by brokers) • Form 1099-S (proceeds from real estate transactions) • Form 1099-K (merchant card and third party network transactions) • Form 1098 (home mortgage interest), 1098-E (student loan interest), 1098-T (tuition) • Form 1099-0 (canceled debt) • Form 1099-A (acquisition or abandonment of secured property) Use Form W-9 only if you area U.S. person (including a resident alien), to provide your correct TIN. If you do not return Form W-9 to the requester with a TIN, you might be subject to backup withholding. See What is backup withholding, later. Cat. No.10231 X Form W-9 (Rev. 10-2018) Contract Form Entity Information Entity Name * VOYA FINANCIAL Contract Name * VOYA STOP LOSS CARRIER Contract Status CTB REVIEW Entity ID* @00049335 ❑ New Entity? Contract ID 8939 Contract Lead * BPETERSON Contract Lead Email bpeterson@weld.gov Parent Contract ID Requires Board Approval YES Department Project # Contract Description* TRANSITION TO VOYA AS THE NEW STOP LOSS CARRIER WHICH WILL PROVIDE SUBSTANTIAL COST SAVINGS TO THE COUNTY. Contract Description 2 Contract Type* AGREEMENT Amount" $0.00 Renewable* NO Automatic Renewal Grant IGA Department Requested BOCC Agenda Due Date HUMAN RESOURCES Date* 12/12/2024 12/16/2024 Department Email CM- HumanResources@weld.g ov Department Head Email CM-HumanResources- DeptHead@weld.gov County Attorney GENERAL COUNTY ATTORNEY EMAIL County Attorney Email CM- COUNTYATTORNEY@WEL D.GOV If this is a renewal enter previous Contract ID If this is part of a MSA enter MSA Contract ID Will a work session with BOCC be required?* HAD Does Contract require Purchasing Dept. to be included? Note: the Previous Contract Number and Master Services Agreement Number should be left blank if those contracts are not in OnBase Contract Dates Effective Date 01/01/2025 Review Date * 10/31/2025 Termination Notice Period Committed Delivery Date Contact Information Contact Info Renewal Date Expiration Date* 12/31/2025 Contact Name Contact Type Contact Email Contact Phone 1 Contact Phone 2 Purchasing Purchasing Approver Purchasing Approved Date Approval Process Department Head JILL SCOTT DH Approved Date 12/16/2024 Final Approval BOCC Approved BOCC Signed Date BOCC Agenda Date 12/23/2024 Finance Approver CHERYL PATTELLI Legal Counsel BYRON HOWELL Finance Approved Date Legal Counsel Approved Date 12/17/2024 12/17/2024 Tyler Ref* AG 122324 Originator BPETERSON Hello