010108 - Clearwater Humana New Case Document 2008 (Executed)t'..
CD]
A&W&5WnNCD)
NCD completed b : Craig Van Natta Date: 11/0712008
Sales Account Representative: Michelle Deemer
Account Installation Representative: Craig Van Natta
A. HCRFz 47N WE,
By signing below, the Employer:
Authorizes Humana to draft the Certificate of Coverage based on the NCD; acknowledges that it is the
Employer's responsibility to review and verify that the NCD and all document drafts are correct and if not
correct to make necessary corrections in a timely manner; and select one of the following:
This authorizes Humana and HumanaDental to build product, plan benefits and process claims based upon
this final approved NCD.
? This authorizes Humana and HumanaDental to build product, plan benefits and process claims based
upon this final approved NCD.
? This authorizes Humana and HumanaDental to postpone product, plan benefit builds and postpone claim
processing until the document is finalized and sign off has been received.
This authorization and agreement is made and entered into by City of Clearwater and Humana, effective
0110112008.
Between the time successor drafts of the NCD are prepared and exchanged, any changes to the documents
describing the Plan for these purposes must be in writing, state the effective date, and must be communicated
to and accepted for claims administration by Humana and HumanaDental in a timely fashion.
It is understood by the Employer that once claim processing has begun, any claims needing to be
reprocessed as a result of changes or corrections to the NCD draft may result in a reprocessing fee. Any
material reduction change to NCD must be communicated to employees within 80 days of the change.
If Client has not executed and returned this Agreement to Humana within 14 days of receipt, or
communicated its revisions, Client is hereby deemed to accept the Agreement and New Case Document in
the form attached.
General Information
® New Client Effective date of Plan: 01/01/2008
? New plan for existing client Effective date of Plan: mmlddlvvvv
? Mid-year plan change Effective date of Plan mmlddlyyyy
-Employer Name: Cit of Cl rwater
Signature:
Title: sIM ou
Authorized Humana Signature:
Title: t?-?
Date:
The Client and Humana have caused this agreement to be executed by their respective officers or
representatives as duly authorized.