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INSURANCE POLICYCIGNA HEALTH AND LIFE INSURANCE COMPANY (Herein called "Cigna") Based on the application for this policy made by City of Clearwater (herein called the Policyholder) and based on the payment of the premium when due, Cigna agrees to reimburse the Policyholder for expenses covered and paid under the terms of this policy. This policy becomes effective at 12:01 a.m. at the Policyholder's address on the effective date shown in the Coverage Information section. All matter printed or written by Cigna on the following pages forms a part of this policy as if recited over the signatures below. This policy is delivered in and is governed by the laws of the jurisdiction shown in the Coverage Information section. In witness thereof, Cigna has caused this policy to be executed at its home office in Bloomfield, Connecticut. Edward P. Potanka, Assistant Secretary t CIGNA HEALTH AND LIFE INSURANCE COMPANY (Herein called "Cigna'9 Table of Contents DEFINITIONS 3 BENEFIT PROVISIONS 7 INDIVIDUAL STOP LOSS COVERAGE 7 DUTIES OF THE POLICYHOLDER 8 EXCLUSIONS 10 OMISSION, CONCEALMENT OR MISREPRESENTATION OF FACT 11 SUBROGATION AND ACTS OF THIRD PARTIES 11 PRIVACY OF INFORMATION 12 PREMIUMS 13 RIGHT TO CHANGE TERMS OF COVERAGE 14 TERMINATION 15 GENERAL PROVISIONS 16 SCHEDULE OF INSURANCE 18 CSL -TOC 2 CIGNA HEALTH AND LIFE INSURANCE COMPANY (Herein called "Cigna") Definitions Section Actual Attachment Point Actual Attachment Point means the amount of Actual Claim Payments above which aggregate stop loss benefits are payable. The Actual Attachment Point is determined at the end of the Policy Year and is the greater of: (1) the sum of all Policy Months in the Policy Year of the number of Covered Persons enrolled during each Lagged Month in each product and plan design in the Benefit Plan multiplied by the Monthly Attachment Factors for that Policy Month; or (2) the sum of the Minimum Attachment Point for each Policy Month. For those policies with run -out coverage, in the year of termination the Actual Attachment Point is the sum of the product as calculated in accordance with the above paragraph plus the Run -out Period Attachment Point. Actual Claim Payment Actual Claim Payment means a payment made on behalf of the Policyholder for a Covered Person under the terms of the Benefit Plan. A payment is deemed to have been made as of the date the payment instrument is issued by the Claim Administrator. An Actual Claim Payment does not include a claim payment made in error on behalf of a Covered Person. Aggregate Individual Stop Loss Limit Aggregate Individual Stop Loss Limit means the limit that is used to determine benefits payable for Aggregate Stop Loss coverage. ASL Benefit Percentage Payable ASL Benefit Percentage Payable means the percentage of Covered Expenses payable to the Policyholder once the Actual Attachment Point has been reached. Become Due Become Due is the earliest date upon which: (a) the Policyholder or the Claim Administrator has received due proof of loss for which a claim is made under the terms of the Benefit Plan, provided such loss is covered under this policy as a Covered Expense; and (b) an Actual Claim Payment has been made. Benefit Plan or Plan Benefit Plan or Plan means the Policyholder's medical benefits and/or other health benefits applicable to either the Individual Stop Loss benefit and/or the Aggregate Stop Loss benefit as uniquely specified for each benefit in the Schedule of Insurance. Claim Administrator Claim Administrator means Cigna or an entity approved by Cigna to provide administrative services and to pay claims for the Policyholder's Benefit Plan. CSL -DEF 3 CIGNA HEALTH AND LIFE INSURANCE COMPANY (Herein called "Cigna '9 Corridor Factor Corridor means the risk retained by the Policyholder. It is expressed as a percentage of Expected Paid Claims and is specified in the Schedule of Insurance. Covered Expenses Covered Expenses for a Policy Year are expenses made under the Benefit Plan that are reimbursable under this policy based on the criteria specified in the Schedule of Insurance. Covered Person Covered Person means a person who is enrolled for coverage and meets the eligibility requirements set forth in the Benefit Plan. Effective Date Effective Date means the date on which coverage begins under this agreement. Expected Paid Claims Expected Paid Claims means the projected claims at the time of the presale or renewal quote to be paid for all Covered Persons during the Policy Year. High Risk Individual High Risk Individual means a Covered Person whose claims under the Benefit Plan are expected to exceed the Individual Stop Loss Limit. For such person(s), a separate Individual Stop Loss Limit for High Risk Individuals is applicable, or such person may be excluded from coverage under this policy. Incurred Incurred means the date on which the supply is obtained or the service is rendered to a Covered Person under the Benefit Plan. Individual Stop Loss Limit Individual Stop Loss Limit means the specific dollar amount of Covered Expenses paid by the Policyholder for each Covered Person during each Policy Year, as set forth in the Schedule of Insurance. If coverage is terminated during any Policy Year, the Individual Stop Loss Limit will be the same as if the coverage had remained in effect for the entire Policy Year. Individual Stop Loss Limit for High Risk Individuals Individual Stop Loss Limit for High Risk Individuals means the specific dollar amount of Covered Expenses paid by the Policyholder for each High Risk Individual during each Policy Year, as set forth in the Schedule of Insurance. If coverage is terminated during any Policy Year, the Individual Stop Loss Limit for High Risk Individuals will be the same as if the coverage had remained in effect for the entire Policy Year. ISL Benefit Percentage Payable ISL Benefit Percentage Payable means the percentage of Covered Expenses payable to the Policyholder once the Individual Stop Loss Limit has been reached. Lagged Month Lagged Month is defined on the Schedule of Insurance as either the same as the current Policy Month or as the Policy Month one or more months prior to the corresponding Policy Month. In the event the Lagged Month refers to a month prior to the Effective Date of the policy, the Lagged Month is defined as the first Policy Month. CSL -DEF 4 1 CIGNA HEALTH AND LIFE INSURANCE COMPANY (Herein called "Cigna") Minimum Attachment Exposure Minimum Attachment Exposure is the greater of the number of Covered Persons enrolled during the Minimum Attachment Lagged Month in each product and plan design in the Benefit Plan; or the original estimated number of Covered Persons at the time of underwriting. Minimum Attachment Lagged Month Minimum Attachment Lagged Month is defined on the Schedule of Insurance as either the same as the Policy Year's first Policy Month or one or more months prior to the Policy Year's first Policy Month. In the event the Minimum Attachment Lagged Month refers to a month prior to the Effective Date of the policy, the Minimum Attachment Lagged Month is defined as the Policy Year's first Policy Month. Minimum Attachment Percentage The Minimum Attachment Percentage is used in computing the Minimum Attachment Point, and if applicable, the Minimum Run -out Period Attachment Point. This percentage is shown on Schedule of Insurance. Minimum Attachment Point The Minimum Attachment Point is either not applicable (in which case it is assumed to have a value of zero in any calculation), or for each Policy Month and for each product and plan design, it is equal to the Minimum Attachment Percentage multiplied by the Minimum Attachment Exposure multiplied by Monthly Attachment factors for the Policy Month. Minimum Run -out Period Attachment Point The Minimum Run -out Attachment Point is the Minimum Attachment Percentage multiplied by the Minimum Attachment Exposure multiplied by the sum of the Terminal Attachment Factors for each month as shown on the Schedule of Insurance under Terminal Attachment Factors. Monthly Attachment Factor Monthly Attachment Factor is a factor assigned to this policy to be used to calculate the Actual Attachment Point and Minimum Attachment Point, as applicable. This factor is shown on the Schedule of Insurance. Policy Month Policy Month means a calendar month during a Policy Year. Policy Quarter Policy Quarter means a period of three consecutive calendar months during a Policy Year, with the first policy quarter beginning on the effective date of the policy. Policy Year Policy Year means the period beginning on the Effective Date of this policy (or most recent renewal date thereof) up to but not including the next renewal date or the date of termination, whichever period is shorter. The Policy Year is specified on the Schedule of Insurance and may differ by coverage as indicated on the Schedule of Insurance. Renewal Date Renewal Date is the day on which a new Policy Year begins as specified on the Schedule of Insurance. CSL -DEF 5 CIGNA HEALTH AND LIFE INSURANCE COMPANY (Herein called "Cigna") Run -out Period Run -out Period is the length of time following the termination date of this policy during which claims that Become Due for a Covered Person under the Benefit Plan will accumulate toward stop loss coverage under this policy provided that they were incurred prior to the termination date of this policy. Run -out Period Attachment Point Run -out Period Attachment Point is the greater of the Minimum Run -out Period Attachment Point or the sum of each product in the Benefit Plan and each month (as shown on the Schedule of Insurance under Terminal Attachment Factors) of the Terminal Attachment Factor multiplied by the number of Covered Persons enrolled during the respective Lagged Month for that month. Terminal Attachment Factor Terminal Attachment Factor is a factor assigned to this policy to be used to calculate the Run -out Period Attachment Point and the Minimum Run -out Period Attachment Point. This factor is shown on the Schedule of Insurance. CSL -DEF 6 CIGNA HEALTH AND LIFE INSURANCE COMPANY (Herein called "Cigna '9 Benefit Provisions Individual Stop Loss Coverage In consideration of payment of the Individual Stop Loss premium by the Policyholder, Cigna shall reimburse the Policyholder for the amount by which the total Covered Expenses for the Policy Year for a Covered Person exceed the Individual Stop Loss Limit. The amount of reimbursement will be calculated by multiplying the amount of Covered Expenses in excess of the Individual Stop Loss Limit times the ISL Benefit Percentage Payable, subject to Cigna's maximum liability specified on the Schedule of Insurance. Reimbursement for Covered Expenses will be made after an Actual Claim Payment is made. Cigna shall not be liable for any expenses that are incurred or become due outside the term of this policy. Other If Cigna is not the Claim Administrator, payment for Covered Expenses will be made after receipt and acceptance by Cigna of such information and records as Cigna may reasonably require regarding the Actual Claim Payments. CSL -BP 7 CIGNA HEALTH AND LIFE INSURANCE COMPANY (Herein called "Cigna '9 Duties of the Policyholder A. The Policyholder will submit to Cigna a complete copy of the Benefit Plan unless Cigna already has such copy in its possession; such Benefit Plan or its complete copy is incorporated herein by reference. B. Any changes to the Benefit Plan will be submitted to Cigna 60 days prior to their effective date. C. If Cigna is not the Claim Administrator, the parties agree that the Policyholder or the Claim Administrator approved by Cigna will have the following duties and obligations: 1. to investigate, audit, calculate and pay all claims in accordance with the provisions of the Benefit Plan and any applicable provider contracts. 2. to provide Cigna such information and records as Cigna may reasonably require for: a. payment of any claim under this policy; and b. projection of future expected claims of the Benefit Plan. 3. to prepare and submit to Cigna on a monthly basis: a. a report of the Actual Claim Payments paid pursuant to the Benefit Plan for that month; b. a report of the total number of Covered Persons covered by the Benefit Plan for that month; and c. a report listing claimants with Covered Expenses during the Policy Year greater than 50% of the Individual Stop Loss Limit. The listing is to include cumulative paid claims and the respective ICD -9 codes. 4. for individual stop loss, the preparation and submission to Cigna on a monthly basis, within 15 days of the previous month's end, of: a. b. a report showing Covered Expenses during the month for those Covered Persons for whom the total Covered Expenses for the stop loss Policy Year meet or exceed 50% of the Individual Stop Loss Limit; and a completed Stop Loss Notification form (to be supplied) which must accompany the report for each listed Covered Person. 5. for any and all Covered Persons whose Covered Expenses meet or exceed the Individual Stop Loss Limit during the Policy Year, the following information must be supplied for claim adjudication under this policy. This information must accompany a Stop Loss Notification form and must be presented to Cigna within 30 days of the end of the month in which the Covered Person exceeded the Individual Stop Loss Limit: a. copies of any and all documentation relating to outside bill reviews /negotiations for hospital bills greater than $15,000 and other provider bills greater than $2,500; b. copies of any and all documentation relating to the Benefit Plan's subrogation interests, if applicable; c. detailed claim reports and check information if explanation of benefits (EOBs) are not available; d. itemized bills for any claims or charges over $5,000; e. an enrollment form or eligibility screen; and f. coordination of benefits (COB) information. CSL -DP 8 ■ • CIGNA HEALTH AND LIFE INSURANCE COMPANY (Herein called "Cigna ") D. The Policyholder will reimburse Cigna for any Actual Claim Payments subsequently repaid, refunded, rebated or owed to the Policyholder by any party. E. The Policyholder will furnish additional information or documentation as reasonably requested by Cigna. CSL -DP 9 • CIGNA HEALTH AND LIFE INSURANCE COMPANY (Herein called "Cigna'9 Exclusions Covered expenses under this policy do not include the following: 1. Actual Claim Payments for which (a) there is other group insurance (including costs recoverable through the application of the coordination of benefits provision in the Benefit Plan); (b) third -party liability has been established; (c) there is coverage pursuant to any plan established by federal, state or local law (to the extent permitted); or (d) there is coverage under workers compensation insurance. 2. Expenses to the extent the Policyholder or Plan receives any payment(s), refund(s) or rebate(s), however denominated, or any reduction in charges including but not limited to reductions as a result of a PPO, EPO, or other managed care arrangement, claim reduction negotiation, or the application of any provider discount arrangement. 3. Expenses which Become Due after the date coverage under this policy ceases. 4. Administrative expenses of the Policyholder or Claim Administrator. 5. Extra contractual damages, expenses or reimbursements of any kind or nature. 6. Investigative or legal expenses including, but not limited to, attorneys' fees and court costs. 7. Expenses Incurred by a person not eligible under the terms of the Benefit Plan. 8. Expenses paid because of an amendment to the Benefit Plan which is not agreed to by Cigna. 9. Expenses for taxes, fees and surcharges that may be imposed on the Benefit Plan or Policyholder by federal, state or local governments. 10. Expenses Incurred as a result of war, whether declared or not, or acts of war or service in any military force of any country while such country is engaged in war, whether declared or not. 11. Expenses which are not considered Covered Expenses under the Benefit Plan. 12. Expenses for which the Policyholder or Claim Administrator has failed to provide the required information set forth under the Duties of the Policyholder section. 13. With respect to individual stop loss, and with respect to aggregate stop loss if indicated on the Schedule, expenses resulting from capitation payments, if any (i.e. contractually determined periodic payments to certain providers based on the number of plan participants entitled to receive services from the provider, in return for which, such providers furnish certain agreed - upon services to eligible plan participants). 14. For liabilities which are non - pecuniary in nature (not having a monetary value). CSL -EX 10 CIGNA HEALTH AND LIFE INSURANCE COMPANY (Herein called "Cigna'9 Omission, Concealment or Misrepresentation of Fact The parties understand that Cigna has relied upon the completeness and accuracy of the underwriting information presented to Cigna in its decision to issue and/or renew this policy. Such information includes information volunteered by the Policyholder when requesting the quote, information provided in response to a request by Cigna, and any personal health statements filled out by persons covered under the Benefit Plan. If Cigna determines that any of the information has omitted, concealed or misrepresented any fact which Cigna determines to have had an effect on Cigna's assessment of the risk, Cigna reserves the right to re- underwrite the coverage, including but not limited to resetting the premium rates, resetting the individual stop limits, resetting or establishing coverage maximums, resetting monthly attachment factors, and minimum attachment factors; or Cigna may terminate this policy. Any such action by Cigna will be reasonable in relation to the nature of the omission, concealment, or misrepresentation, and may be retroactive to the beginning of the Policy Year. Subrogation and Acts of Third Parties Applicability Where allowed by law, this section will apply: 1. to Policyholders who receive payments for Covered Expenses under this policy; and 2. where Actual Claim Payments have been made under the Benefit Plan to a Covered Person who has a lawful claim against, or who has received compensation, damages or other payment from another party or parties for expenses resulting in the payment by Cigna of such Covered Expenses; and 3. to the Policy Year in which the corresponding payment was made. The expense of subrogation will be shared proportional according to the Benefit Plan. Policyholder Obligations To secure the rights of Cigna under this section, the Policyholder must: 1. pursue the rights of subrogation contained in the Benefit Plan; and 2. reimburse Cigna for Covered Expenses Incurred under this policy (but not more than the amount paid by the other party or parties) if payment from the other party or parties has been received by the Policyholder. The Policyholder must reimburse Cigna first, and in full, before retaining any benefit from the recovery; and 3. assign to Cigna the Policyholder's subrogation and/or reimbursement right contained in the Benefit Plan to the extent of Cigna's payments if requested by Cigna and Policyholder shall cooperate fully and do all things as necessary and required to enable Cigna to pursue the recovery right. CSL -OSP 11 CIGNA HEALTH AND LIFE INSURANCE COMPANY (Herein called "Cigna '9 Privacy of Information In connection with the performance of its obligations under this policy, Cigna may disclose to and receive disclosure from the Policyholder or its Claim Administrator of information collected or received in connection with Covered Expenses reimbursable under this policy, provided the information is limited to that which is reasonable and necessary. Under no circumstances will Cigna provide the Policyholder with information on incurred, but not paid claims, projected claims, pre - certifications of coverage, case management notes, and course of treatment information or prognosis information. CSL -OSP 12 t • CIGNA HEALTH AND LIFE INSURANCE COMPANY (Herein called "Cigna '9 Premiums Premium Payments The initial premium shall be due and payable on the first day of the month of this policy. Subsequent premiums shall be due on the first day of each calendar month that this policy remains in effect. Premiums can be paid to Cigna's home office or to an authorized agent of Cigna. Each premium paid continues the policy in force until the date the next premium is due, except as set forth in the Grace Period section. The total monthly premium is the sum of the premium for all Covered Persons for all coverages as identified on the Schedule of Insurance. Grace Period A period of 31 days, without interest, is allowed for paying any premium other than the first premium payment. The policy will remain in force during the grace period, unless Cigna has been advised in writing that the policy is to cease prior to the end of the grace period. If any premium is not paid before the grace period ends, the policy will cease at the end of the grace period. When this policy ends the Policyholder will be liable for all premiums past due and unpaid, including a pro -rata premium for any time this policy remains in force during the grace period. Premium Refund Any error or correction of any premium paid must be reported to Cigna promptly. The premium will be adjusted retroactively to reflect the correct premium amount. If a correction will result in a decrease in premium, a refund will be given only for the two month period prior to Cigna's receipt of a correction request. CSL -PREM 13 a CIGNA HEALTH AND LIFE INSURANCE COMPANY (Herein called "Cigna") Right to Change Terms of Coverage Cigna reserves the right to change any of the terms shown on the Schedule of Insurance including but not limited to the Individual Stop Loss Limits, the Monthly Attachment Factors, the Terminal Attachment Factors, Minimum Attachment Factors and/or Premium Rates under the following circumstances: 1. In the event the total number of Covered Persons at the beginning of the Policy Year or at any time during the Policy year differs more than 10% from the original estimated enrollment, such change to become effective on the first day of any month following the fluctuation, subject to advance written notice of at least 45 days. 2. In the event enrollment in any covered plan at the beginning of the Policy Year or at any time during the Policy year differs more than 10% from the original estimated enrollment, such change to become effective on the first day of any month following the fluctuation, subject to advance written notice of at least 45 days. 3. In the event of material changes in the Benefit Plan or changes in legislation or regulation, Cigna may revise the premium rates with the revision to become effective on the date such changes are effective. 4. In the event of the addition of a subsidiary, operation or class of Covered Persons not previously covered under the Benefit Plan and approved by Cigna, Cigna may revise the premium rates with the revision to become effective on the date such addition is effective. 5. In the event of the termination of a subsidiary, operation or class of Covered Persons covered under this policy, Cigna may revise the premium rates with the revision to become effective on the date such termination is effective. 6. On any policy anniversary, subject to advance written notice of at least 45 days. 7. In the event of an omission, concealment or misrepresentation of material fact, as described in Omission, Concealment or Misrepresentation of Fact section, such change to become retroactively to the first day of the affected coverage period. If Cigna is not the Claim Administrator, Cigna also reserves the right to change any premium rates if Cigna determines that Actual Claim Payments are not being made in accordance with the provisions of the Benefit Plan. Such adjustment may be made retroactive to the beginning of the Policy Year. CSL -TERM 14 CIGNA HEALTH AND LIFE INSURANCE COMPANY (Herein called "Cigna'9 Termination This policy will continue in effect from its effective date until terminated on the earliest of the following: 1. At the end of the grace period if the premium is not paid. 2. Upon mutual consent by the parties, on the date the parties agree to terminate. 3. On the premium due date following 45 days after the mailing of written notification of termination by Cigna or the Policyholder. 4. On the date of termination of the Benefit Plan. 5. If any state or other jurisdiction enacts a law which prohibits the continuance of this policy, or the existing law is interpreted to so prohibit the continuance of this policy, as reasonably determined by Cigna, the policy shall terminate automatically as to such time or jurisdiction on the effective date of such law or interpretation. 6. Immediately upon written notice to the Policyholder of the discovery of the Policyholder's failure to comply with any material term of the policy. 7. Immediately upon written notice to the Policyholder if Cigna reasonably determines that the Policyholder has ceased or failed to sufficiently fund its account established to fund benefit payments under the Plan. This policy may also be terminated by Cigna as follows: 1. Retroactively to the Policy Effective Date or the latest Renewal Date as applicable, upon written notice to the Policyholder, if Cigna determines that any of the information has omitted, concealed or misrepresented any fact which Cigna determines to have had an effect on Cigna's assessment of the risk. 2. On the next premium due date, at Cigna's option, if Cigna determines that Actual Claim Payments are not being made in accordance with the provisions of the Benefit Plan. 3. On the effective date of a change in the Benefit Plan which is not approved by Cigna. Cigna will give the Policyholder written notice within 45 days after receipt of a copy of such change. 4. On the effective date of any change in Claim Administrator which is not approved by Cigna. Cigna will give the Policyholder written notice within 45 days after receipt of notification of such change. All coverage ceases upon termination of this policy. The termination of this policy does not excuse the Policyholder from forwarding to Cigna any and all premiums accrued through the date of termination. Cigna reserves the right not to provide Run -out coverage in the event of termination prior to the end of the Policy Year. CSL -TERM 15 CIGNA HEALTH AND LIFE INSURANCE COMPANY (Herein called "Cigna'9 General Provisions Notice This policy provides benefits when the Policyholder's Benefit Plan incurs expenses in excess of the individual and/or aggregate limits as outlined in this policy. Since this policy insures the Policyholder and not the individuals covered by the Policyholder's Benefit Plan, this policy neither adds to nor subtracts from the terms of the underlying Benefit Plan. Additionally, this policy does not in any way affect the Policyholder's responsibility to comply with employment laws such as the Americans with Disabilities Act, the Age Discrimination in Employment Act, Title VII of the 1964 Civil Rights Act and other applicable state and federal laws. Parties to the Policy and Responsibility for Claims for Benefits by Covered Persons The parties to the policy are the Policyholder and Cigna. There are no third party beneficiaries and this policy does not create any rights or legal relation whatsoever between Cigna and a Covered Person under the Policyholder's Benefit Plan. Cigna's sole liability under this policy is to the Policyholder. The Policyholder shall retain the exclusive obligation for any action, brought for benefits under the Policyholder's Benefit Plan however denominated, including any action purporting to be brought with respect to this policy. Policyholder agrees to assume the tender of any such action and to reimburse Cigna for reasonable costs, costs of whatever kind (including court costs and attorneys' fees) which Cigna may incur to protect its and Policyholder's rights until Policyholder accepts tender. Provided that nothing herein shall alter Cigna's obligations contained in the parties' administrative services agreement, if any. Entire Contract The parties agree that this policy and any endorsement and amendment to the policy constitute the entire contract regarding the stop loss insurance between the parties. Any endorsement or amendment changing this policy must be in writing and must be signed by authorized officers of Cigna and the Policyholder respectively. No person may modify or waive any of the terms of this policy except by a written amendment signed by a duly authorized officer of Cigna. Enforceability In the event that one or more provisions in this policy shall, for any reason, be held to be invalid, illegal or unenforceable, the validity, legality or enforceability of the other provisions of this policy shall not be affected. Clerical Error Clerical error by the Policyholder or by Cigna will not continue terminated coverage. In the event of such clerical error, an appropriate adjustment will be made. Examination and Maintenance of Records If Cigna is not the Claim Administrator: 1. The Policyholder will fumish to Cigna such data as may be required for the administration of this policy. 2. The Policyholder's and the Claim Administrator's books and records pertaining to the policy will be available to Cigna for inspection during the usual business hours. Such books and records will be maintained for a period of not less than 6 years following termination of the policy. 3. Cigna will have the right at all reasonable times to inspect all records relating to Actual Claim Payments paid under the Benefit Plan whether maintained by the Policyholder or the Claim Administrator. Cigna will treat as confidential all such records and information obtained. CSL -GP 16 CIGNA HEALTH AND LIFE INSURANCE COMPANY (Herein called "Cigna") Dispute Resolution The Policyholder may not initiate any dispute resolution relating to a claim under this policy fewer than 60 calendar days or more than five years after due proof of such claim is furnished to Cigna. Plan Changes Cigna reserves the right to approve a change in the Benefit Plan. The Policyholder must promptly furnish Cigna with a copy of each change in the Benefit Plan prior to its effective date. If such copy is not received, Cigna will only be liable for the reimbursement of Covered Expenses under this policy as if the plan was not changed. Subcontracting The work to be performed by Cigna under this policy may be performed wholly or in part through an authorized representative, subsidiary, affiliate, or parent of Cigna. Such subcontracting will not increase or diminish the rights or obligations of either party to this policy. Assignment No assignment of this policy by the Policyholder will be binding upon Cigna. Offset Cigna shall be entitled to offset payments due to the Policyholder under this policy against premiums due and unpaid by the Policyholder to Cigna. CSL -GP 17 t. • CIGNA HEALTH AND LIFE INSURANCE COMPANY (Herein called "Cigna '9 Schedule of Insurance Coverage Information Policyholder: City of Clearwater Policy Number: 2499162 Effective Date: January 01, 2014 Issue Date: January 31, 2014 Next Renewal Date: January 01, 2015 State or other Jurisdiction of Issue: Florida Notices For the purpose of any notices required under this policy, such notices should be sent to the addresses shown below: Cigna Health and Life Insurance Company 900 Cottage Grove Road, Hartford, CT 06152 Attn: Stop Loss Unit For questions regarding coverage or to get help in resolving a complaint, the phone number is: 1 -855- 246 -1874 City of Clearwater 100 S. Myrtle Ave. Clearwater, FL 33756 Attn: Allen Del Prete allen.delprete @myclearwater.com 727 -562 -4876 CSL -SCH 18 CIGNA HEALTH AND LIFE INSURANCE COMPANY (Herein called "Cigna '9 Individual Stop Loss Policy Year: January 01, 2014 to December 31, 2014 Covered Expenses: Claims that are incurred between January 01, 2014 and December 31, 2014 and that Become Due between January 01, 2014 and December 31, 2016 Monthly Premium Rates: For each covered employee $41.04 ISL Benefit Percentage Payable: 100% Cigna shall reimburse the Policyholder 50% of the first $100,000.00 Covered Expenses paid for a Covered Person in a Policy Year that are in excess of the Individual Stop Loss Limit, and 100% of additional Covered Expenses paid for a Covered Person in a Policy Year. Individual Stop Loss Limit: $250,000.00 The following Covered Persons have been identified as High Risk Individuals and shall be subject to the Individual Stop Loss Limit as specified below: High Risk Individuals None Benefit Plans Covered by Individual Stop Loss Coverage: Claim Administrator Product Cigna Cigna Open Access Plus Pharmacy Expense Cigna's maximum liability per individual: Will be the individual maximum, if any, as set forth in the Benefit Plan less the Individual Stop Loss Limit Payment of premium is considered acceptance of this policy and the terms within. CSL -SCH 19 Countersigned: -- cteonc t cecV tcof George N. Cretekos Mayor Approved as to form: Leslie K. Dougall- Assistant City Atto CITY OF CLEARWATER, FLORIDA By: Attest: William B. Home II City Manager L Rosemarie Call City Clerk