102207 - Humana - Employer Group Application - SIGNEDHUMANA.
Gupdance when you need it most
Life and Short-Term Income Protection plans insured or
administered by Humana Insurance Company
PPO, EPO and Indemnity plans offered by Humana Health
Insurance Company of Florida, Inc.
HMO plans offered by Humana Medical Plan, Inc.
HUM ANA
DENTAL
Prepaid Basic, Intermediate and High Dental
plans underwritten by The Dental Concern, Inc.
Prepaid Capitol II, Universal II, SGX290, SGX245,
5Gx185A, SG245D, SG290, SG245, and SG185A
Dental plans provided by SafeGuard Health
Plans, Inc. All other Dental plans insured or
administered by Humana Dental Insurance
Company Internal use only
Group number:
Employer Group Application FLORIDA
WUMANA 1 HUMANADENTAL
Please refer to your proposal to complete this application.
Print clearly in black ink, and answer all questions or indicate "not applicable."
Your Business Profile
Business name Federal tax ID number - ?02Sq - City of C]P_,qrw;44-P_r Location address (not a P.O. Box) 10 0 South Myrtle Avenue
City Clearwater County Pinellas State FL Zip 33756
Do you have more than one location? A No CI Yes
Billing address (if different)
City County State Zip
Nature of business or SIC number Munici pality 91 99 Date company established
Business status: ? Corporation ? Partnership ? Sole Proprietorship )W Other: (explain) Municipality
Business phone number ( 727) 562-487 5 Fax number ( 127) 562-4877
Management contact Allen Del Prete -
Administrative contact Anna Fierstein
Management contact e-mail addressAllgn. Del Pre te@myclearwa ter. com_
continued on next page -
FL-80123-BP 1012003 Reorder# FL-99555-BP 7/2007
Requested effective date
How many employees are on your payroll?
How many hours per week must your employees work to be eligible? 7
For large employer groups (51 or more employees), select between 20 an?40?2s. Hrs
For small employer groups (2-50 employees) and business groups of one, select between 25 and 40 hours.
Do you want to exclude a class of employees?
197
4 7?
No ? Yes
If yes, check class to exclude: (Options vary by plan. Refer to the Underwriting Requirements for each plan.)
? union ? nonunion ? hourly ? salary ? management ? non-management
How long must employees wait after hire date to become eligible? ? 0 days ? 30 days ? 50 days
7 st of the month followinq Date of Hire ? 90 days **Other, specify:
How many employees are eligible for coverage?
New employee effective date provision: A First of month following waiting period
(required for HMO and Prepaid Dental plans)
? Immediately following waiting period
For Dental and Life plans, the employee termination date coincides with the effective date provision.
Are any present or former employees/dependents currently on or eligible to elect COBRA/State Continuation? ? NoA Yes
If yes, enter information below. Attach a separate sheet if necessary.
Name of applicant Qualifying event (e. g., termination
of employment, divorce, etc.) Date of
qualifying event Date COBRA or State Continuation
coverage terminates
See ai-A-ached List
The following applies to al l companies and products
The companies listed on this Employer Group Application, severally or
collectively as the context may require, are referred to in this application as
we, us and our.
You, the participating employer, policyholder, contractholder, or group
plan sponsor, intend to establish, sponsor, and endorse an employee
benefit plan which will be governed by Employee Retirement Income
Security Act of 1974 {ERISA}, You are the ERISA plan administrator.
Small employer means a person, sale proprietor, self employed individual,
independent contractor and firm, corporation, partnership or association
actively engaged in business, which employed an average of at least one
but not more than 50 employees on business days during the preceding
calendar year and who employs at least one employee on the first day of
the plan year. Entities that are affiliated companies or that are eligible to
file a combined tax return for the purpose of taxation, are considered one
employer.
You agree to make available your records which we determine are
relevant to this application and group coverage for inspection by the
Trustee, Administrator, us or our representative during your normal
business hours.
As claims administrator with authority to make claim determinations as
described in Section 503 of ERISA, we make final decisions under the
Policy or Group Plan with respect to paying claims for benefits, including
deciding appeals of denied claims. As claims administrator, we shall have
full and exclusive discretionary authority to 1) interpret Policy or Group
Plan provisions, 2) make decisions regarding eligibility for coverage and
benefits, and 3) resolve factual questions relating to coverage and
benefits.
You understand and agree that failure to remit and pay premium when
due will be considered a default in premium payment, and that coverage
will be terminated by us, following a grace period of 31 days from the
date of non-payment of premium. We may terminate your coverage
according to the termination section of the Policy or Group Plan. Except
for non-payment of premium or when a group or individual is not or has
not been eligible for coverage, you will be provided with a 45 day advance
written notice, unless a greater period is expressly specified in the Policy. If
coverage is terminated by us for non-payment of premium, you will still
owe and we will collect all due premium including premium for the grace
period.
For you to remain eligible for the Policy or Group Plan, the eligibility,
underwriting and participation requirements must be maintained, for each
respective coverage. Failure to maintain the plan eligibility, underwriting
and participation requirements will terminate your coverage under the
Policy or Group Plan. You will be provided with a 45-day advance written
notice of termination. Other termination provisions are stated in the Policy
or Group Plan.
Based upon our standard underwriting practice, we may require an
employee or dependent to submit Evidence of Health Status. We have the
right to use the information provided by you and any applicant (employee
or dependent) to determine whether coverage will be provided, to
determine eligibility and to establish appropriate premiums. Any health
related information that has been provided will not be used to decline
medical coverage unless permitted by law.
The following applies to dental Prepaid benefits provided by SafeGuard Health Planst Inc.
You, the policyholder, intend to establish, sponsor, and endorse an With respect to paying claims for benefits or determining eligibility for
employee benefit plan which will be governed by the Employee Retirement coverage under this policy or group plan, HumanaDental Insurance
Income Security Act of 1974 {ERISA}, You are the ERISA plan administrator. Company or SafeGuard Health Plans, Inc. shall have full and exclusive
Prepaid Limited Health Service Organization is a unique joint venture discretionary authority to: 1) interpret policy provisions, 2) make decisions
between HumanaDental Insurance Company and SafeGuard Health Plans, regarding eligibility for coverage and benefits, and 3) resolve factual
Inc. designed to build high quality, cost effective dental care delivery. questions relating to coverage and benefits.
Under this agreement, the two companies are partners in a marketing and
administration agreement.
FL-80123-BP 1012003 Reorder# FL-99555-BP 212007
100 or more total employees on payroll
Humana Large Group Medical FLORIDA
EMPLOYER GROUP APPLICATION
Plan: Option: If plan 1 option number is available, the remainder of the plan selection does not need to be completed.
If seiectinq the
if plan and option number is not available, please indicate product narrie:
Product Name{s} (as shown on your proposal): ?j
? Health Care Flexible Spending Account (FSA) Cl Dependent Care Flexible Spending Account (FSD)
? Personal Care Account offered with Plan: Option: ? Health Savings Account
Underwriting requirements
• Refer to your proposal for complete underwriting requirements.
9 Underwriting approval is required to offer more than one medical
carrier to your employees.
• If you do not maintain eligibility, underwriting, and participation
requirements, we will terminate your coverage.
Group information
Are any affiliations or subsidiaries to be covered? ANo ? Yes If yes, Li Affiliation LI Subsidiary
Affiliation/subsidiary information. Name
Address
Number of employees Number c f employees Number of employees
Total number of Number of employees waiving with other waiving without other in waiting period
eligible employees to he covered now qualifying coverage qualifying coverage (da not include in eligible count)
How much will you contribute to premium? Employee $ or % Employee/Spouse $ or %
Employee/Child $ or % Family $ or %
Additional classes and corresponding number of employees to be included: LJ Seasonal ? Part-time
LJ Other explain (e.g., contract employee, independent contractor, directors):
Will this plan coverage replace any existing or previously in-force group plan? LI No jjxyes
If yes, carrier name termination dat
iI-_ri_it-er_-pupa-? th-C-are _ 12/31/07
Are there any disabled dependents over the age of 19 to be covered in this group. ? No AYes
(If yes, please provide on a separate sheet of paper name of employee, social security number, dependent name, statement of disability/diagnosis from
attending physician, dependency statement from employee and the current group carrier insuring the dependent.)
To the best of your knowledge, how many group members had total claims over $15,000 in the past year that are still active on the plan?
Please provide details: yes, see attached
Member status Condition or diagnosis Total medical costs Prognosis
Retiree information
Are you offering coverage to retirees? ? No Yes If yes, required age: minimum years of service:
FL-80123-LG Thank you for choosing Humana. Reorder# FL-99555-LG 712006
Employer Agreement
You, the employer, understand, agree and represent:
• You have read this document and the information you provided is accurate and complete to the best of your knowledge and can he
substantiated by your business records.
¦ You have received and reviewed a proposal and the applicable regulatory information required by your state-
¦ Neither you nor the agent/broker/producer has the authority to waive a complete answer to any question, determine coverage or
insurability, alter any contract, bind us by making any promise or representation, or waive any of our other rights or requirements. No
waiver or change will bind us unless signed by an authorized officer of our company.
• The first month's estimated premium (which may include a monthly administrative fee), and fully completed enrollment information for
all eligible persons requesting insurance coverage must be submitted with this application before action is taken on this application.
¦ You will collect any employee contribution toward premium. Our acceptance of premium does not guarantee coverage.
¦ You will provide the documentation requested by us which establishes that all eligibility, underwriting, and participation requirements of
the plan are met.
• Only individuals who meet the eligibility requirements of the plan are eligible to maintain coverage.
• Providing incomplete, inaccurate, or untimely information may void, reduce, or increase past premium, or terminate an individual's
coverage or the group's coverage.
This document will form part of any contract issued. Coverage is not in effect unless and until you receive written notification from us- If
this application is declined, we will return the premium deposit submitted with this application.
Do not cancel any current group coverage until you receive written notice from us that we have issued coverage.
Any person who knowingly and with intent to injure, defraud or deceive any insurer files a statement of claim or an application containing
any false, incomplete or misleading information is guilty of a felony of the third degree.
Dated on: 10116(0-7 By: ala,1 _
(month, ate, year) {empl yer signature} -`
Dated at: @atr?? n t ? f u~ Re-foJrCe, 1 API't7or
(city (title)
Agent/Broker/Producer information
General Agency
General agency information pertains to Agent/Agency of Record #1 L1 Agent/Agency of Record #2
Name (print) Gehring Grow Tax ID Number
65-0361295
Address C' Stat Zip Code
1. Agent/Agency of Record (for commissions and correspondence): FL, 3 3 410
Name (print ?Ujt Gehring Tax ID/Social Security Number
266069658
State Agent License ID NumberA4 94 9 7 3 ..
Commission split: LAXNo ? Yes If yes, percentage: (total should equal 100%)
1. Writing Agent/Broker/Producer:
Name (print) Social Security Number
Commission split: LJ No ? Yes If yes, percentage: (total should equal 100%)
2. Agent/Agency of Record {for split-commissions):
Name (print) Tax ID/Social Security Number
State Agent License ID Number
Percentage of sales: LJ No ? Yes If yes, percentage: (total should equal 100%)
2. Writing Agent/Broker/Producer:
Name (print) Social Security Number
Percentage of sales: ? No ? Yes If yes, percentage: (total 100%)
As the Writing Agent/Broker/Producer, I acknowledge that I am responsible to meet with the employer submitting this application in order
to fully and accurately represent the terms and condition of the plans and services of the offering or insuring entity, or one of its
subsidiaries and have no knowledge of 4y replac e f coverage other than as indicated in this application- These provisions are
available to me and the employer V u a Technical Information Guide or other plan literature.
Writing Agent's Signature: Date:
FL-80123-BP 1012003 Reorder# FL-99555-BP 212007
GEHRING,,AGROUP
.2 PROFESSIONAL SERVICES
October 22, 2007
Michelle Deemer, Sales Executive Commercial Sales
Humana Inc.
5401 W. Kennedy Boulevard, Ste. 161
Tampa, FL 33609
RE: City of Clearwater - Employer Group Application
Dear Michelle:
Enclosed please find the following documents for City of Clearwater's medical insurance
implementation with Humana:
a Original Signed Prospect Analysis -- Please be advised that this document was
completed to the best of our knowledge. Due to the privacy of the information
requested, we do not have all details asked.
Original Signed Employer Group Application
• Attachment 1- Current COBRA Participant Listing
Attachment 2 -- Employer Contribution Schedule (these are the bi-weekly rates)
Please process this information for a January 1, 2008 effective date. If you have any
questions or concerns, please do not hesitate to contact me (561) 626-6797.
Stephanie Drost, Director - Account Management
Gehring Group
Enclosures (4)
cc: Kurt Gehring, President CEO, Gehring Group
Ellen Jones, Director - Risk Management, Gehring Group
Julie Curtis, Senior Account Manager, Gehring Group
11505 FAIRCHILD GARDENS AVENUE Is SUITE 202 m PALM BEACH GARDENS, FL 33410
PHONE 561.626.6797 ¦ FAx 561.626.6970 ¦ TOLL-FREE 800.244.3696 ¦ www.gehringgroup.com
FOR HUM?ANAICHOICECARE USE ONLY
Prospect Number Date Received
HU'MANA. SM Approval
(guidance when you need it most PROSPECT ANALYSIS
1. Complete both sides of this form. Shaded areas need not be completed for
employers where the insurance rates are based on claims experience.
2. The premium rates quoted for the prospective employer's Group Plan will be based
upon information submitted regarding eligible employees with respect to age/sex
demographics, place of residence and proposed effective date. HumanalChoiceCare
reserves the right to change rates if information submitted during the actual enrollment
differs from the information submitted for purposes of this analysis.
3. HumanalChoiceCare relies on the information in this Prospect Analysis and the Group
Application in order to set rates and to determine the risk. Misrepresentation of
information in any portion of this analysis or Group Application may result in the denial
of coverage, or, after coverage is effective, rescission of the policy.
4. DO NOT terminate any existing coverages until you receive written acceptance by
HumanalChoiceCare Health Care Plans of your application.
5. In addition to this Prospect Analysis, the following material must be submitted to
ensure prompt processing of your application:
?• Group Application
¦ Initial Premium Deposit Nced In,v0K-e.
k/¦ Current Benefits Booklet (PPO or Dual Option Sales)
• Recent Billing Statement or Prior Subscriber Listing (PPO or Dual Option Sales)
• Employee Enrollment Forms
GENERAL INFORMATION
Name of Gompany/Applicant Nature of Business Number of Years in Business
City of Clearwater Municipality 193
GROUP HEALTH CARRI
United Healthcare
ELIGIBILITY/PARTICIPATION
INFORMATION
1/1/2006 12131/200
From Thrrninh
RETIREES ? SEASONAL EMPLOYEES ? PART-TIME EMPLOYEES (< 30 Hours)
? ANY INDIVIDUAL NOT DIRECTLY EMPLOYED BY APPLICANT (e.g., Contract Employee, Independent
Contractors, Directors)
Do all employees live ? DIES If NO. Location of other HumanalChoiceCare Number Employees Location Outside HumanalChoiceCare Number Employees
Service Area (s} Service Area(s)
in the local
HumanalChoiceCare ? NO
service area?
OVER 0
luneck all of the tollowing to be covered (if checked, provide details in Comments section).
Please answer the following questions for all active and retired employees, spouses and dependent children to be
covered by the Group Plan. (Provide details for all "YES" answers in Comments section.)
YES NO
1. Has anyone been denied coverage for medical reasons, or issued coverage with a conditional ?
waiver?
2. In the last 12 months, has any insurance company or HMO declined to renew your coverage ?
or declined to offer coverage to your employees? (If YES, please provide the name of the provider and
the reason.
3. Has anyone been treated for a serious illness, been hospitalized or had surgery in the ?
past twelve months?
*e. ., Cancer, Diabetes, Cardiovascular Disease, AIDS Substance Abuse Obesity, etc.
4. Does anyone have a continuing claim from an existing mental or physical disorder, or ?
anticipate hospitalization for any reason?
5. Has anyone incurred health care claims in excess of $15,000 in the last 12 months? ?
6. Is anyone currently disabled, incapacitated or confined in a hospital, nursing home or ?
treatment facility?
7a. Are there any handicapped dependents over age 19 to be covered in this group? (If YES, ?
provide name of employee, social security number, dependent names, statement of disability/diagnosis from
attending physician and dependency statement from employee.)
7b. If the answer to 7a. is YES, are these handicapped dependents insured by current group ?
carrier?
8. Are any former employees and/or their dependents currently covered through COBRA ?
continuation? (If YES, provide name, social security number, health status, qualifying event, and effective
date.
9. Do employees eligible for COBRA continuation pay premiums directly to employer's current ? [X
carrier?
10. Are any employees or their dependents pregnant? (If YES, please provide name, relationship and due ?
datG.)
11. Are all employees covered by Worker's Compensation? (If No, what employees or class of Ek ?
employees are not covered?
COMMENTS
Applicant Signature
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Form C'_. Humana
Replacement Commission Agreement
This document establishes a replacement tornrrissior schedule for.fcustiomername] Cf
identified by the following group number(s) [lfstaligroup and aWoWn numbers only rf a rgtMw Gssaj
This schedule replaces the applicable Humana Producer Partnership Plan commission schedule.
These guldelines apply to all Replacement Commissilon Agreements:
*RWaoament commissions must be expressed as a flat perc:sntage of premium. Fractlonal percentages up to two
deWmal places are acceptable. Sliding scale alternate commission ach eduia are not acceptable.
*Replacement commissions that exceed Humana's guidelines must be disclosed to, and approved by, an
authorized representative, of the employer by completing the "Client Ackno wledgmenr section on the bottom of the
alfrsrrater Version of this form,.
*Replacement commissions that generate commissions abova the standard commissions payable for government
entitles must be disclosed to and approved by an authorized representative of tha,government entity by rornpleting
the "Client Acknowledgment" section on the bottom of the: alternate version of ths form.
*The cost of any commissions in excess of the standard. commission schedule will be added to the premium paid
by the employer.
*This farm should also be used when eliminating commissions for fee-based consulting groups. Simply put zeros
In all the-appropriate boxes and note that the use is Motif sold.without commissions:
Please replace the standard commissloft with the following replacement commissions (caressed as a
perconb9a of premlem) that will be patd.ftat the above. named case (leave blank any lines that do not apply);
OPlacemont Commission as a Ffat Other
Pemehtage of Premium (in place of Medical Dental Life
the standard commisslon schedule
First Year Conanaiealons (Fiat 1.5% %
Renewal Commissions (Flat % %
Stitrt data (must: be original (J
effective drate or ronswel titrte : (??
f
Dated this &-, day of "2 0s
Agent of itteeard's SfAsture
Prtntec! sme Agent Tax. ID #
Hu DirectinrlY Signature
Printed Nm 9 Hu Au a Di ectorN1P
[ HumsM Underwriting Approval, . [ Humana Unden+ Ung AppinVal. j
iav. 312QD'7