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HomeMy WebLinkAboutexhibit 4-applicationThe MEGA Life and Health Insurance Company SPECIVIAN SIC Code: Home Office Use Only PARTICIPATING EMPLOYER APPLICATION (1) Participating Employer: City of Miami (Correct Legal Name) (2) Address: 444 S.W. 2'°1 Avenue, 6th Floor Street City County State Zip Code (3) (a) Type of Ownership: Corporation X Partnership ❑ Proprietorship ❑ (b) Nature of Business: Municipality (4) The above Participating Employer requests participation of its Employees under the applicable Group Insurance Policies and Riders issued to: The Trustees of the [ABC Employers Trust] Group Insurance Policy Number: L123451 (5) SUBSIDIARY OR AFFILIATED EMPLOYERS: The employees of the following subsidiary or affiliated employers request participation: Name Street City State Zip Code NA Address (6) ELIGIBILITY: (a) CLASSES ELIGIBLE: All Employees in the following classes who work at least hours per week are eligible for insurance: SHR-APP-E-01 1 Miami Class Definition I Part -Time / Temporary Employees (b) EXCLUDED EMPLOYEES: (c) DATE OF ELIGIBLI TY: PRESENT EMPLOYEES who have completed Days active employment, except those excluded above, shall be efigible311436tsurance on the desired effective date of coverage requested in Section 12. ALL OTHER EMPLOYEES who have completed Days of active employment, except those excluded above, shall be eligible for insurance on the first day of the (insurance month) (pay period) coinciding with or next following the date they complete the required period. (7) PRIOR GROUP INSURANCE PLAN: Will this replace any existing group insurance? ❑ Yes X No If Yes, give name of prior insurance company and date of termination: (8) WORKERS' COMPENSATION: Are all eligible employees covered by Workers' Compensation? X Yes ❑ No (9) THE SCHEDULE OF BENEFITS , this day of SELECTED BY THE PARTICIPATING , EMPLOYER .(Schedule of Benefits inserted here or separate page attached) (10) PREMIUM SCHEDULE: [ Weekly ] Plan EmoI Participating Employer: Signature of Officer: EmDlovee & I Dependent Level 1 $7.25 $17.75 Typed Name of Offiae26.85 Level 2 $13.25 $32.75 kt9.65 $76.25 Level 3 $20.25 $50.25 (11) PREMIUM PAYMENT AND GRACE PERIOD: The premium is to be payable monthly, within 20 days after the end of each premium accounting period. This policy has a 31 day grace period This provision means that if a renewal premium is not paid on or before the date it is due, it may be paid during the following grace period. The grace period will not apply if, at least 30 days before the premium due date, We have delivered or mailed to the Participating Employer's last address shown in Our records written notice of Our intent not to renew this policy. During the grace period, the policy will stay in force. If the premium is not paid by the end of the grace period, the policy will terminate on that date. (12) DESIRED'FECTIVE DATE: The 1st day of , 20 provided this application has been accepted in writing by The MEGA Life and Health Insurance Company. The Coverage, if issued, shall be subject to all the terms and conditions of the Policy to which this Application is attached. 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 at SHR-APP-E-0I 2 Florida Licensed Agent: Company: Address: Title of Offic er: Signature of Florida Date: Florida Agent 1D#: Telephone #: THE MEGA LIFE AND HEALTH INSURANCE COMPANY 1331 W. Memorial Road, Suite 112 Oklahoma City, OK 73114 Certificate of Insurance issued under terms of Group Insurance Policy No. [1 2345] issued to [DEF Company] a Participating Employer in the [ABC Employers Trust] (herein called the Holder) Policy Date: [January 1, 2002] The MEGA Life and Health Insurance Company hereby certifies that members of the class(es) eligible for insurance are insured under the above Policy as determined by those provisions titled Conditions and Effective Date of Insurance. This certificate is evidence of insurance provided under the Policy. All benefits are paid according to the terms of the Policy. This certificate describes the essential features of the insurance coverage. President Secretary SHR-CERT-01 1 Rev I. Table of Contents Section Certificate of Insurance Face Page Table of Contents 1• Classes 11. Benefit Specifications III. Definitions IV. Conditions and Effective Date V. Benefit Specifications VI. Termination of Insurance VII. Conversion Privilege Vlll. Transitional Coverage IX. Uniform Provisions X. COBRA XI. SHR-CERT-01 2 Rev II, Classes Classes Eligible for insurance: if Part -Time Employees of DEF Company] Effective Date Information: [January 1, 2002] Open Enrollment Period for Medical Expense Benefits: [January 1] through [January 31] during each Calendar Year. SHR-CERT-01 3 Rev III. Benefit Specifications [Benefits for Insured Persons [and Dependents] Plan [125] Accidental Death Benefit: [(Level 1)] [$10,000.] for an Insured Person [[$10,000.] for a Dependent spouse [$10,000.] for each Dependent child] Basic Medical Expense Benefit [(Sickness]: Maximum Benefit per Coverage Year: Cash Deductible per Coverage Year: Participation Rate: Physician Office Visit Benefit: Physician Office Visit Copayment: Participation Rates: [$ 1,000.] per Covered Person [$ 50.] per Covered Person [80%] of Covered Expenses in excess of the Cash Deductible or Copayment amounts [$ 151 per Covered Person per visit [100%] of the service charge made by the Physician for the Office Visit. [80%], in excess of the Cash Deductible, for any Related Charges in connection with the Office Visit, whether or not performed on the same day. Notes: Related Charges include, but are not limited to charges for the following: Injections, laboratory, pathology, radiology, diagnostic testing and venipuncture. Covered charges subject to the Physician Office Visits Copayment amount are not subject to the Cash Deductible, but do apply towards the Basic Medical Expense Benefit Maximum. [Additional] Accident Benefit: [(Payable after Basic Medical Expense Benefit exhausted)] Maximum Benefit per Occurrence: Maximum Number of Occurrences per Coverage Year: Cash Deductible per Occurrence: Participation Rate: [$1,000.] per Covered Person [NIA] [$ 50.] per Covered Person [80°/0] of Covered Expenses in excess of the Cash Deductible amount.] SHR-CERT-01 4 Rev Benefit Specifications [Benefits for Insured Persons [and Dependents] - Plan [1 45] Accidental Death Benefit: [(Level 2)1 [$15,000.] for an Insured Person [[$15,000.] for a Dependent spouse [$15,000.] for each Dependent child] Basic Medical Expense Benefit [(Sickness)]: Maximum Benefit per Coverage Year: Cash Deductible per Coverage Year: Participation Rate: Prescription Benefit: Maximum Benefit per Coverage Year: Participation Rate: Prescription Copayment: Physician Office Visit Benefit: Physician Office Visit Copayment: Participation Rates: [$ 1,000.] per Covered Person [$ 1001 per Covered Person [80%] of Covered Expenses in excess of the Cash Deductible or Copayment amounts [$ 150.] per Covered Person and applied to Basic Medical Expense Benefit Maximum [80%] of Covered Expenses in excess of the [Cash Deductible : Copayment] amount [$151 for Generic / [$25] for Name Brand [$ 10.] per Covered Person per visit [100%] of the service charge made by the Physician for the Office Visit. [80%], in excess of the Cash Deductible, for any Related Charges in connection with the Office Visit, whether or not performed on the same day. Notes: Related Charges include, but are not limited to charges for the following: Injections, laboratory, pathology, radiology, diagnostic testing and venipuncture. Covered charges subject to the Physician Office Visits Copayment amount are not subject to the Cash Deductible, but do apply towards the Basic Medical Expense Benefit Maximum. SHR-CERT-01 5 Rev Plan [145] (Con't) [Additional] In -Hospital Medical [(Payable after Basic Medical Expense Benefit Daily In -Hospital Benefit: Participation Rate: Surgery Benefit: Maternity Benefit: Cash Deductible per Coverage Year: Participation Rate: Maximum number of Occurrences Per Coverage Year: Expense Benefit [(Sickness)]: exhausted)] [$ 300.] Per day for up to [5] days per Covered Person per Coverage Year [80%] of Covered Expenses [$1,000] Per Covered Person per Occurrence [$1,000] Per Covered Person per Occurrence [$ 100] Per Covered Person [80%j of Covered Expenses in excess of the Cash Deductible amount. [NIA] [Additional] Accident Benefit: [(Payable after Basic Medical Expense Benefit exhausted)] Maximum Benefit per Occurrence: Maximum Number of Occurrences per Coverage Year: Cash Deductible per Occurrence: Participation Rate: [$2, 000.] per Covered Person [NIA] [$ 100.] per Covered Person [80%] of Covered Expenses in excess of the Cash Deductible amount.] SHR-CERT-01 6 Rev Benefit Specifications [Benefits for Insured Persons [and Dependents] - Plan (165] Accidental Death Benefit: [(Level 3)] [$25,000.] for an Insured Person [($25,000.] for a Dependent spouse [$25,000.] for each Dependent child] Basic Medical Expense Benefit [(Sickness)]: Maximum Benefit per Coverage Year: Cash Deductible per Coverage Year: Participation Rate: Prescription Benefit: Maximum Benefit per Coverage Year: Participation Rate: Prescription Copayment: Physician Office Visit Benefit: Physician Office Visit Copayment: Participation Rates: [$1,000.] per Covered Person [$ 150.] per Covered Person [80©1] of Covered Expenses in excess of the Cash Deductible or Copayment amounts [$ 250.] per Covered Person and applied to Basic Medical Expense Benefit Maximum [80%] of Covered Expenses in excess of the [Cash Deductible: Copayment] amount ($15] for Generic / [$25] for Name Brand [$ 10.] per Covered Person per visit [100%] of the service charge made by the Physician for the Office Visit. [80%], in excess of the Cash Deductible, for any Related Charges in connection with the Office Visit, whether or not performed on the same day. Notes: Related Charges include, but are not limited to charges for the following: Injections, laboratory, pathology, radiology, diagnostic testing and venipuncture. Covered charges subject to the Physician Office Vsits Copayment amount are not subject to the Cash Deductible, but do apply towards the Basic Medical Expense Benefit Maximum. SHR-CERT-01 7 Rev Plan [165] (Con't) [Additional] In -Hospital Medical [(Payable after Basic Medical Expense Benefit Daily ln-Hospital Benefit: Participation Rate: Surgery Benefit: Maternity Benefit: Cash Deductible per Coverage Year: Participation Rate: Maximum number of Occurrences Per Coverage Year: Expense Benefit [(Sickness)]: exhausted)] [$ 300.] Per day for up to (51 days per Covered Person per Coverage Year [80%] of Covered Expenses [$1,000] Per Covered Person per Occurrence [$1,000] Per Covered Person per Occurrence [$100] Per Covered Person [80%] of Covered Expenses in excess of the Cash Deductible amount. [N/A] [Additional] Accident Benefit: [(Payable after Basic Medical Expense Benefit exhausted)] Maximum Benefit per Occurrence: Maximum Number of Occurrences per Coverage Year: Cash Deductible per Occurrence: Participation Rate: [$3,0001 per Covered Person [N/A] [$ 150.] per Covered Person [80%] of Covered Expenses in excess of the Cash Deductible amount.] SHR-CERT-01 8 Rev Benefit Specifications [Benefits for Insured Persons [and Dependents] In -Hospital Indemnity Benefit Part A: In -Hospital Indemnity Daily Benefit: [$1,000.] per day Maximum Benefit Period Per Period of Hospital Confinement: [1] day Per Coverage Year: [1] period of Hospital confinement Part B: In -Hospital Indemnity Daily Benefit: [$100.] per day Maximum Benefit Period Per Period of Hospital Confinement: [100] days Per Coverage Year: [3] periods of Hospital confinement] SHR-CERT-01 9 Rev Benefit Specifications [Benefits for Insured Persons Short Term Disability Benefit [Option I: Weekly Benefit: [$125] Elimination Period Accident: [0] Days Sickness: [7] Days Day of Total Disability on Which Benefit Begins Accident: [1st] Day Sickness: [81 Day Maximum Benefit Period: [28] Weeks] [Option II: Basic Coverage: Weekly Benefit: [$250] Elimination Period Accident: [0] Days Sickness: [7] Days Day of Total Disability on Which Benefit Begins Accident: [1st] Day Sickness: [81 Day Maximum Benefit Period: [13] Weeks Extended Coverage: Payable after [13] Week Basic Coverage Monthly Benefit: [$1,000] Maximum Benefit Period: [18] Months] An Insured Person is covered for Total Disability due to pregnancy only if the Total Disability starts after she has been insured without break for 9 months. Benefits are limited to a maximum of 6 weeks for any one pregnancy, and there is no Elimination Period.] SHR-CERT-01 10 Rev Benefit Specifications Benefits for Insured Persons [and Dependents] [Life Amount of Life Insurance Employee [$10,000] Spouse [$5,000] Each Child [$2,000] The amount of Life Insurance in force for a Covered Person age 70 or over or attaining age 70 after becoming insured shall be reduced by 50%.] [Dental See List of Covered Dental Procedures.] SHR-CERT-01 11 Rev IV Definitions Any word in the male gender equally applies to the female gender unless a distinction is specified. ["Child" includes Your natural children. It also includes adopted children, stepchildren and other children provided: 1. They depend upon You for support; and 2. They have a parent -child relationship with You. If both parents of a Child are Insured Persons, the Child will be considered as a Dependent of either parent. The Child may not be considered a Dependent of both parents.] "Covered Person" means an Employee [or Dependent] who is insured under the policy. ["Dependent" means: 1_ Your spouse; 2. Unmarried children who are under 19 years of age; and 3. Unmarried children who are 19 years of age through 25 years of age if the child: a. Is attending an accredited school full-time; and b. Is financially dependent upon You for support] "Employee" means a person who is: 1. Employed by an Employer contributing to the Holder; and 2. Eligible for insurance according to the Holder's Rules of Eligibility which have been agreed to by Us. "Individual" means an Employee . "Insured Person" or "You" means an Employee who is insured under the policy. "We," "Our" or "Us" means The MEGA Life and Health Insurance Company. SHR-CERT-01 12 Rev Terms have different meanings when applied to Life Insurance than they have with - respect to Health Insurance. [The following definitions apply only to the Life Insurance coverage: "Injury" means bodily injury caused by an accident. The accident must occur while coverage is in force. "Sickness" means sickness or disease. The Sickness must commence while insured under the policy.] [The following definitions apply only to the Accidental Death, Dental, Short Term Disability, In -Hospital Indemnity and Health Insurance coverage: "Accident" means a sudden, unexpected and unforeseen, identifiable event producing at the time objective symptoms of an Injury. The Accident must occur while the Insured is covered under this Policy. "Authorities" means: 1. Textbooks: a. Cecil Textbook of Medicine, (newest edition, W. B. Saunders Company, Publisher); b. Scientific American Medicine, (newest update, Scientific American, Inc., Publisher); c. Conn's Current Therapy, (newest edition, W. B. Saunders Company, Publisher); d. Schwartz Principles of Surgery, (Newest edition, McGraw-Hill, Publisher); e. Nelson's Textbook of Pediatrics, (Newest edition, W. B. Saunders Company, Publisher); f. Sabiston's Textbook of Surgery, (Newest edition, W. B. Saunders Company, Publisher). 2. Periodicals: a. edical Letter, b: Journal of American Medical Association; c. New England Journal of Medicine; d. Disease -a -Month, (Mosby -Yearbook, Inc., Chicago, IL). SHR-CERT-01 13 Rev "Complications of Pregnancy" means: - 1. Conditions, requiring Hospital confinement (when the pregnancy is not terminated), whose diagnoses are distinct from pregnancy but are adversely affected by pregnancy or are caused by pregnancy. Examples are acute nephritis, nephrosis, cardiac decompensation, missed abortion and similar medical and surgical conditions of comparable severity. False labor, occasional spotting, Physician prescribed rest during the period of pregnancy, moming sickness, hyperemesis gravidarum, pre-eclampsia and similar conditions associated with the management of a difficult pregnancy not constituting a nosologically distinct complication of pregnancy are not considered "Complications"; 2. Non -elective caesarean section; 3. Ectopic pregnancy which is terminated; 4. Spontaneous termination of pregnancy which occurs during a period of gestation in which a viable birth is not possible. "Complications of Pregnancy" as defined above are covered under the policy to the same extent as any other Sickness. "Coverage Year" means a consecutive 12-month period or any part of such period, beginning on an Insured Person's effective date of coverage and ending on the certificate anniversary date. Each Covered Person will be required to satisfy a new Cash Deductible for each Coverage Year. "Creditable Coverage" means prior health benefits coverage that may include any of, or a combination of, the following: 1. A group health plan; 2. A health insurance plan or health maintenance organization (HMO) plan; 3. An individual health insurance policy; 4. COBRA continuation of coverage; 5. A health plan under Chapter 55, Title 10, United States Code pertaining members of the uniformed services of the United States; 6. Medicare or Medicaid; 7. A medical care program of the Indian Health Service or of a tribal organization; 8. A,Siate health benefits risk pool; 9. A health plan offered under FEHBP (chapter 89 of Title 5, United States Code); 10- A health plan under section 5(e) of the Peace Corps Act; or 11. A public health plan. "Custodial Care" means care which is designed to help a person in the activities of daily living. Continuous attention by trained medical or paramedical personnel is not necessary. Such care may involve: 1. Preparation of special diets; 2. Supervision over medication that can be self-administered; and 3. Assisting the person in getting in or out of bed; to walk; to bathe; to dress; to eat; and to use the toilet. SHR-CERT-01 14 Rev "Dental Treatment Plan" is a Dentist's report, on a form satisfactory to Us which: 1. Itemizes the dental services recommended; 2. Shows the charge to be made for each dental service; and 3. Is accompanied by supporting pre -operative X-rays or other diagnostic materials as We may require. "Dentist" means a duly licensed dentist acting within the scope of his license_ It includes a Physician furnishing covered dental services which he is licensed to perform. He may not be a Covered Person or a member of a Covered Person's Immediate Family. A Dentist is considered a health care provider. "Emergency Care" means medical care and treatment provided after the sudden onset of a medical condition manifesting itself by acute symptoms, including severe pain, which are severe enough that the lack of immediate medical attention could reasonably be expected to result in any of the following: 1. The patient's health would be placed in serious jeopardy; 2. Bodily function would be seriously impaired; 3. There would be serious dysfunction of a bodily organ or part. "Experimental/Investigational Treatment" includes: 1. Medical devices; 2. Drugs and/or pharmaceutical agents; and 3. Procedures or treatments; as defined below: 1. Medical device if any of the following applies: a. It does not have FDA approval to be marketed; or b. It has a 510K number, and its use is other than for the purpose or in the manner for which the original FDA approval was received. Final determination of the similarity of use per the original approval will be made by Us; or c. It has FDA approval to be marketed or has a 510K number, and its use is not in bcordance with the FDA approval guidelines/instructions; or d. The device, alone or in combination with any drug, pharmaceutical agent, other medical device, procedure or treatment performed by a Physician or under a Physician's supervision, is not currently reported by one of the Authorities listed to be safe and effective for the treatment of the disease or condition for which the device is being used; SHR-CERT-01 15 Rev 2. Drugs and pharmaceutical agents if any of the following applies: a. It does not have FDA approval to be marketed; or b. Its use does not conform to FDA licensing; or c. The drug or pharmaceutical agent, alone or in combination with any other drug, pharmaceutical agent, other medical device, procedure or treatment performed by a Physician or under a Physician's supervision, is not currently reported by one of the Authorities listed to be safe and effective for the treatment of the disease or condition for which such drug or pharmaceutical agent is being used; 3. Procedures or treatments performed or rendered by a Physician or under a Physician's supervision if any of the following applies: a. It requires the use of a medical device, drug or pharmaceutical agent which would be considered experimental/investigational under this policy; or b. It is not currently reported to be safe and effective by one of the Authorities listed; or c. The use of such procedure or treatment, alone or in combination with any drug, pharmaceutical agent, other medical device, procedure or treatment performed or rendered by a Physician or under a Physician's supervision, is not currently reported by one of the Authorities listed to be safe and effective for the treatment of the disease or condition for which the procedure or treatment is performed or rendered. "FDA" means the United States Food and Drug Administration. "Hospital" means an establishment which: 1. Holds a license as a Hospital (if required in the state); 2. Operates primarily for the reception, care and treatment of sick or injured persons as inpatients; 3. Provides around the clock nursing service; 4. Has a staff of one or more Physicians available at all times; 5. Provides organized facilities for diagnosis and surgery; 6. Is not primarily a clinic, nursing, rest or convalescent home or a Skilled Nursing Fa9ility or a similar establishment and 7. Is not, other than incidentally, a place for treatment of drug addiction. The nursing service must be by registered or graduate nurses on duty or call. The surgical facilities may be either at the Hospital or at a facility with which it has a formal arrangement. Confinement in a special unit of a Hospital used primarily as a nursing, rest or convalescent home or Skilled Nursing Facility will not be deemed to be confinement in a Hospital. SHR-CERT-41 16 Rev "Hospital" also includes a licensed ambulatory surgical center. The center must have permanent facilities and be equipped and operated primarily for the purpose of performing surgical procedures. The types of procedures performed must permit discharge from the center in the same "'working day." The center will not qualify as a "Hospital" if: 1. Its primary purpose is performing abortions; 2. It is maintained as an office by a Physician for the practice of medicine; or 3. It is maintained as an office for the practice of dentistry. "Hospital" also includes a licensed emergency treatment center. The center must have permanent facilities and: 1. A Doctor of Medicine (M.D.) or Doctor of Osteopathy (D.O.) present at all times; 2. An M.D. specialist representing each of the major specialties available within minutes; 3. Ancillary services, including laboratory and X-ray, staffed at all times; and 4. A pharmacy staffed, or on call, at all times. "Immediate Family" means the spouse, children, brothers, sisters or parents of a Covered Person. "Injury" means bodily injury caused by an accident. The accident must occur while coverage is in force as to the Covered Person. It must also result directly and independently of all other causes in Toss covered by the policy. "Intensive Care Unit" means a section within a Hospital which is operated exclusively for critically ill patients. It must provide special supplies, equipment and constant observation and care by registered nurses or other highly trained hospital personnel. It does not include any hospital facility maintained for the purpose of providing normal post -operative recovery treatment or service. "Medicare" means benefits under Title XVIII of the Social Security Act of 1965, as amended. "Necessary Treatment" means medical or dental treatment necessary to treat a covered Sickness or Injury and which is consistent with currently accepted medical or dental practice. Any: 1. Medical device; 2. Drug or pharmaceutical agent; 3. Procedure or treatment; or confinement or expense in connection therewith which is Experimental/Investigational in nature is not considered "Necessary Treatment". If services are not considered to be: 1. Medically necessary; or 2. Consistent with professionally recognized standards of care with respect to quality, frequency or duration; expenses related to those services will not be deemed "Necessary Treatment". SHR-CERT-01 17 Rev "Nurse Midwife" means a licensed Registered Nurse who is certified as a Nurse Midwife by the American College of Nurse -Midwives and is authorized to practice as a Nurse Midwife under state regulations. "Occurrence" means a period of Injury or Sickness. An occurrence is deemed to have ended when 60 consecutive days have passed during which the Covered Person: 1. Received no medical treatment, services, or supplies for an Injury or Sickness; and 2. Neither took any medication, nor had any medication prescribed, for an Injury or Sickness. "Open Enrollment Period" means the number of days each year during which Employees [and their Dependents] may enroll for health coverage under this plan. The Open Enrollment Period is shown in the Benefit Specifications. "Participation Rate" means the percentage of Usual and Customary charges that are payable by Us after the Deductible or Copayment. "Physician" means a licensed practitioner of the healing arts acting within the scope of his license. He may not be a Covered Person or a member of a Covered Person's Immediate Family. "Physician" includes a duly Certified Nurse Midwife with respect to treatment, service or care rendered by such Nurse Midwife within the lawful scope of practice of a duly Certified Nurse Midwife. "Rare Disease or Condition" means a disease or condition having fewer than 1,000 new cases diagnosed in the most recent 5-year period in the United States. In the case of a Rare Disease or Condition for which treatment is not reported in one of the Authorities listed, We may: 1. Select independent medical consultants from those who are certified and/or experienced in the appropriate specialty of any of the 23 specialty boards certified by the American Board of Medical Specialties; or; 2. Rely on medical publications We recognize as reputable to determine whether a medical device, drug, pharmaceutical agent, procedure or treatment is experimental/investigational. The final determination as to whether it is experimental/investigational will be made by Us. "Reported" means an article which has been published or accepted for publication in a textbook Speer reviewed periodical. "Sickness" means sickness or disease which causes Toss covered by the policy. The loss must commence while the Covered Person is insured. Pregnancy is considered a Sickness. SHR-CERT-01 18 Rev "Special Enrollee" means an Employee [or Dependent] who previously declined health coverage under the plan, but has experienced one of the following events; 1. Loses other health insurance coverage[; 2. Becomes a Dependent, or acquires a Dependent, due to marriage; 3. Becomes a Dependent, or acquires a Dependent, due to a birth, adoption or placement for adoption in the Employees home; or 4. Has a court order requiring coverage be provided for a spouse or Dependent Child]. Special Enrollees may join the plan if any of the above events should occur. In order to be eligible for coverage, the Special Enrollee must submit a request for enrollment and pay any required premium within 31 days of the event. Any Special Enrollee who does not request coverage within 31 days will not be able to enroll until the plan's next Open Enrollment Period. "Total Disability" means, for an Insured Person, inability to perform the substantial and material duties of his occupation or employment. The inability must be as a result of Injury or Sickness. "Total Disability" means, for a retired person, [and a Dependent spouse,] inability to engage in the substantial and material activities engaged in prior to the start of disability. The inability must be as a result of Injury or Sickness. ["Total Disability„ means, for a child, confinement to the house or a Hospital. The confinement must be as a result of Injury or Sickness.] "Usual and Customary" means the fee regularly charged and received for a given service by the health care provider that does not exceed the general level of charges being made by providers of similar training and experience when furnishing customary treatment for a similar Sickness, condition or Injury. The locality where the charge is incurred will also be considered. The term locality" means a county or Such greater area as is necessary to establish a representative cross section of providers regularly furnishing the type of treatment, services or supplies for which the charge was made.] SHR-CERT-01 19 Rev V, Conditions and Effective Date Individuals who are or become a member of an eligible class are eligible for insurance on the first of the policy month. Class is defined in the application. [A person may not be covered as both an Insured Person and as a Dependent. If he qualifies as both then he may be insured only as an Insured Person and not as a Dependent] Before any insurance will be effective, the Individual or Special Enrollee must agree to pay the premium and make written request to the Holder. The request must be on forms provided by Us for that purpose. If he does these things, the Individual's insurance [and that of his Dependents] will take effect as follows: 1. On the date the Individual becomes eligible, if request is made on or before such date; or 2. On the date of request, if the request is made within 31 days after the Individual's eligibility date. If the Individual does not make the request within the 31 day time period, the Individual [and his Dependents] may not enroll in the plan until the next Open Enrollment Period. Coverage will take effect on the day immediately following the Open Enrollment Period. Any change from one plan of insurance to another will occur only during an Open Enrollment Period. SHR-CERT 01 20 Rev [Effective Date of Health Insurance for Newborn or Adopted Children A child born to You or Your insured dependent spouse will automatically become insured as a Dependent. The effective date of coverage will be the date of birth. Coverage will be to the same extent as is provided for other covered dependent children. Such coverage includes: 1. The Necessary Care and Treatment of medically diagnosed congenital defects; 2. Birth abnormalities; 3. Prematurity; 4. Routine nursery care. A child adopted by You or Your insured dependent spouse will automatically become insured as a Dependent. The effective date of the coverage will be the earlier of: 1. The date of placement for the purpose for adoption; or 2. The date on which You assume a legal obligation for total or partial support of the child. Coverage will be to the same extent as is provided for other covered dependent children and will include the necessary care and treatment of pre-existing medical conditions. Coverage will continue for -the adopted child unless the placement is disrupted prior to the final adoption; and 1. The child is permanently removed from placement; 2. The legal obligation terminates; or 3. You rescind, in writing, the agreement of adoption or agreement assuming financial responsibility. In the event additional premium is required for such child, then the insurance will terminate 31 days from the date of birth or placement for adoption unless written request to continue insurance is made to the Holder within 31 days from the date of birth or placement for the purpose for adoption] Changes in Amount of Insurance A change in the amount of a Covered Person's insurance will be effective on the date of change top one eligible class to another. However, if You are not available for work on that date the change will be delayed until You are available for work. [If an insured Dependent is confined in a Hospital on that date, the change in Health Insurance for that Dependent will be delayed until the day after the end of the confinement] The change is subject to the payment by You of any required premium contribution. SHR-CERT-01 21 Rev VL Benefit Descriptions [Life Insurance If a Covered Person should die while insured under the policy, We will pay the amount of life insurance in force on the Covered Person's life at the time of death. Payment will be made in one sum to the beneficiary designated by the Covered Person. Payment will be made upon Our receipt of due proof of death. If there is no surviving named beneficiary, payment will be made to the Covered Person's estate. In such case, at Our option, payment may be made to any one or more of the following relatives: wife, husband, father, mother, child or children, brothers or sisters. Change of Beneficiary The Covered Person may name a new beneficiary at any time by filing with the Holder a written request on forms furnished by Us. The Holder will send the request to Us. When the request is received by Us from the Holder the change will relate back to and take effect as of the date it was signed. This is the case whether the Covered Person is alive or not when We receive the request. Even though the change of beneficiary will relate back to the date it was signed it will be without prejudice to Us on account of any payment We have already made. Benefit Limitations No coverage is provided for loss caused by or resulting from: 1. Death as a result of aviation or any air travel or flight; 2. Death while the Covered Person is a resident outside the continental United States and Canada; or 3. Death within 2 years from the Covered Person's effective date of coverage as a result of suicide, while sane or insane.] SHR-CERT-01 22 Rev Occidental Death Benefit If a Covered Person suffers a loss of life due to an Accident, We will pay the following, subject to the Maximum in the Benefit Specifications, provided such loss: 1. Is incurred within 365 days after an Accident; and 2. is the result of an Injury sustained in such Accident. Change of Beneficiary The Covered Person may name a new beneficiary at any time by filing with the Holder a written request on forms furnished by Us. The Holder will send the request to Us. When the request is received by Us from the Holder the change will relate back to and take effect as of the date it was signed. This is the case whether the Covered Person is alive or not when We receive the request. Even though the change of beneficiary will relate back to the date it was signed, it will be without prejudice to Us on account of any payment We have already made. Benefit Limitations No coverage is provided for loss caused by or resulting from: 1. Declared or undeclared war; or any act of war; 2. Death within 2 years from the Covered Person's effective date of coverage as a result of suicide, while sane or insane; 3. Medical or surgical treatment of Sickness or disease; or 4. Flight in any kind of aircraft, except while riding as a passenger on a regularly scheduled flight of a commercial airline.] SHR-CERT-01 23 Rev [Short Term Disability Benefit If You suffer Total Disability, We will pay the Weekly Benefit to You during Your Total Disability for each week that You remain so disabled beyond the Elimination Period. This is subject to: 1. Your being under the regular care of a Physician; 2. No benefit is payable for the Elimination Period; 3. Benefits will stop when the Maximum Benefit Period is reached or when You cease to be totally disabled: 4. The Weekly Benefit is made up of 7 daily segments; 5. A period of less than a full week will be calculated on a daily basis. (The Weekly Benefit; Day Benefits Begin; and Maximum Benefit Period are to be found in the Benefit Specifications.) Successive Disabilities If You are totally disabled at different times, while the policy is in force, from the same or a related condition, all of those times will be treated as on continuous period of Total Disability. This is the case unless there is a lapse of 6 months between disabilities. If there is, then the subsequent Total Disability will be deemed not to be related to the prior one and will be considered a new period of Total Disability. All disabilities due to the same pregnancy are considered as one period of Total Disability. Benefit Limitations No coverage is provided for loss caused by or resulting from: 1. Injury or Sickness arising out of or in the course of employment; or which is compensable under any Workers' Compensation or Occupational Disease Act or Law. 2. Declared or undeclared war; or any act of war; or participation in a riot or civil disturbance; 3. The Insured Person's commission of a felony; 4. Any period of disability during which the Insured Person is not under the regular care of a Physician; 5. Mental or nervous disorders, alcoholism, or any form of substance abuse; 6. Intentionally self-inflicted Injury or suicide attempt while sane or insane. SHR-CERT-01 24 Rev Limitation for Pre -Existing Condition Benefits for this coverage shalt not be payable for a Pre -Existing Condition. A condition for which an Insured Person has been medically diagnosed, treated by, or sought advice from, or consulted with, a Physician during 6 months before he became insured is a Pre -Existing Condition. This provision will cease to apply to any disability resulting from a Pre -Existing Condition after a period of 12 continuous months of coverage. What happens if we are replacing an existing disability contract? You will receive credit toward satisfaction of the Pre-existing Condition time periods under Our policy for the time You were covered under the Holder's prior policy. We will apply the time covered under the Holder's prior policy and if Your disability is due to a Pre-existing Condition, the benefits shall be the benefits payable under Our policy. Waiver of Premium We will waive premium for an Insured Person during the period of Total Disability for which the Weekly Benefit is payable under the policy provided: 1. Total Disability began while the Insured Person was insured under the policy; and 2. Total Disability has existed continuously for a period of not less than one pay period. During this period, the Insured Person's insurance will remain in force. This provision is subject to the Termination of Insurance provision, except.for the payment of premium.) SHR-CERT-01 25 Rev [In -Hospital Indemnity Benefit If a Covered Person is confined to a Hospital, We will pay benefits for such Hospital confinement as shown in the Benefit Specifications. This benefit is in addition to any other benefits under the policy. Limitation for Pre -Existing Condition Benefits for this coverage shall not be payable for a Pre -Existing Condition. A condition for which a Covered Person has been medically diagnosed, treated by, or sought advice from, or consulted with, a Physician during the 6 months before he became insured is a Pre -Existing Condition. This provision will cease to apply to any expenses incurred in connection with a Pre - Existing Condition after the earliest of: 1. The end of a continuous period of 6 months of coverage, the final day of which must occur after the Covered Person's effective date of insurance, during which: a. No expense is incurred; b. No diagnosis or treatment or advice is received; and c. A Physician is not consulted; as the result of the Pre -Existing condition or any related condition; 2. 12 months of continuous coverage. The Pre -Existing Condition Limitation above does not apply to newborn or adopted children, nor to any pregnancy. Any Pre -Existing Condition limitation can be reduced by that period of time the Covered Person was previously insured for the condition causing claim; provided such Covered Person: 1. Was validly insured under his prior plan with Creditable Coverage, immediately prior to becoming insured under this policy; and 2. Became insured under this policy within 63 days after termination of his prior coverage. Benefit Limitations Hospital confinement which does not constitute Necessary Treatment is not covered. Coverage is not provided for any period of confinement for which a charge is not customarily made in the absence of insurance. No coverage is provided for loss caused by or resulting from: 1. Injury or Sickness arising out of or in the course of employment; or which is compensable under any Workers' Compensation or Occupational Disease Act or Law; 2. Declared or undeclared war; or act of war; 3. The Covered Person's commission of a felony; 4. Hospital confinement which is not ordered by or under the written direction of a Physician; SHR-CERT-01 26 Rev 5. Cosmetic surgery. This does not apply to: a. Reconstructive surgery incidental to or following surgery resulting from trauma, infection, or other diseases of the involved part; or b. [Reconstructive surgery because of a congenital disease or anomaly of a covered Dependent newborn or adopted infant; orb c. Reconstructive surgery on a non -diseased breast to restore and achieve symmetry between two breasts following a mastectomy. 6. Any period of Custodial Care confinement; 7. The treatment of mental or nervous disorders, alcoholism, or any form of substance abuse, except as specifically provided; 8. Intentionally self-inflicted Injury or suicide attempt while sane or insane. No benefits will be paid for any expense incurred after the date the policy terminates.] SHR-CERT-01 27 Rev [Health Insurance Benefits A. Basic Medical Expense Benefit - Plan [12011401160] If a Covered Person incurs Covered Expenses listed below [while not Hospital confined] as the result of [an Injury or] Sickness, We will pay for such Usual and Customary expenses which constitute Necessary Treatment while insured for this benefit. Benefits are payable at the applicable Participation Rate and are subject to the Maximum Benefit, Cash Deductible and Copayment stated in the Benefit Specifications. B. [Additional] In -Hospital Medical Expense Benefit - Plan [1401160] If a Covered Person incurs Covered Expenses listed below while Hospital confined as the result of [an Injury or] Sickness, We will pay for such Usual and Customary expenses which constitute Necessary Treatment while insured for this benefit. [This benefit is supplemental to any Basic Medical Expense Benefit in force under the policy. It will be provided only after such Basic Medical Expense Benefit has been exhausted.] Benefits are payable at the applicable Participation Rate and are subject to the Maximum Benefit and Cash Deductible stated in the Benefit Specifications. Benefits are limited to the Maximum Number of Occurrences stated in the Benefit Specifications. C. [Additional] Accident Benefit - Plan [12011401160] If a Covered Person incurs Covered Expenses listed below, We will pay for such Usual and Customary expenses which constitute Necessary Treatment and are incurred: 1. As the result of an Injury; 2. While insured for this benefit; and 3. Within 90 days from the date of the Injury. [This benefit is supplemental to any Basic Medical Expense Benefit in force under the policy. It will be provided only after such Basic Medical Expense Benefit has been exhausted.] Benefits are payable at the applicable Participation Rate and are subject to the Maximum Benefit and Cash Deductible stated in the Benefit Specifications. Benefits are limited to the Maximum Number of Occurrences stated in the Benefit Specifications. SHR-CERT-01 28 Rev List of Covered Expenses 1. Hospital room, board and general nursing services; 2. Charges made by a Hospital for medical services and supplies, including emergency room services; 3. Operating and recovery room charges; 4. Charges made by a Physician for medical care, treatment or for performing a surgical procedure; 5. Charges made for diagnostic tests; 6. Charges made for radiation and chemotherapy treatment 7. Charges made for the cost and giving of an anesthetic; 8. Charges for private duty nursing by an R.N. or L.P.N. while Hospital confined and when ordered by a Physician; 9. If a Prescription Benefit is shown in the Benefit Specifications, charges for drugs and medicines requiring the written prescription of a Physician and dispensed by a licensed pharmacist; 10. Charges for rental of durable medical equipment used in the patient's home. If purchase would cost Tess, then that is the amount allowed; 11. Charges for artificial limbs, eyes and other prosthetic devices (except for replacement); 12. Charges for casts, splints, trusses, crutches and braces (except dental braces); 13. Charges for oxygen and rental of equipment for the giving of oxygen; 14. Charges for physical therapy given by a Physician; 15. Chafges for ambulance service to and from a local Hospital (a licensed ambulance must be used); SHR-CERT-01 29 Rev 16. Charges for a minimum of forty-eight hours of inpatient care following a vaginal delivery and minimum of ninety-six hours of inpatient care following delivery by ceasarean section for a mother and her newborn in a Hospital or Birthing Center. Shorter hospital stays are allowed if recommended by the attending health care provider in consultation with the mother and one postpartum visit is performed within 48 hours of discharge. Charges for expenses incurred for a postpartum follow-up visit. Such visit must occur within 48 hours of discharge from a Hospital or Birthing Center and be performed by a licensed health care provider whose scope of practice includes postpartum home care. Coverage includes: a. Physical assessment of the covered mother and newborn child; b. Parent education; c. Training or assistance with breast or bottle feeding; and d. The performance of any appropriate clinical tests. At the covered mother's discretion the visit may occur at the heath care provider's facility or Hospital. 17. Charges for reconstructive breast surgery, including augmentation mammoplasty, reduction mammoplasty, and mastopiexy resulting from a mastectomy. Coverage is also provided for all stages of reconstructive breast surgery performed on a non -diseased breast to establish symmetry with the diseased breast and for protheses and physical complications at all stages of the mastectomy. Covered Expenses will be considered to be incurred when the services are performed or the purchases are made. SHR-CERT-01 30 Rev Limitation for Pre -Existing Condition Benefits for this coverage shall not be payable for a Pre -Existing Condition. A condition for which a Covered Person has been medically diagnosed, treated by, or sought advice from, or consulted with, a Physician during the 6 months before he became insured is a Pre -Existing Condition. This provision will cease to apply to any expenses incurred in connection with a Pre - Existing Condition after the earliest of: 1. The end of a continuous period of 6 months of coverage, the final day of which must occur after the Covered Person's effective date of insurance, during which: a. No expense is incurred; b. No diagnosis or treatment or advice is received; and c. A Physician is not consulted; as the result of the Pre -Existing condition or any related condition; 2. 12 months of continuous coverage. The Pre -Existing Condition Limitation above does not apply to newborn or adopted children, nor to any pregnancy. Any Pre -Existing Condition limitation can be reduced by that period of time the Covered Person was previously insured for the condition causing claim; provided such Covered Person: 1. Was validly insured under his prior plan with Creditable Coverage, immediately prior to becoming insured under this policy; and 2. Became insured under this policy within 63 days after termination of his prior coverage. SI-IR-CERT-01 31 Rev Benefit Limitations Coverage is not provided for services, supplies or equipment for which a charge is not customarily made in the absence of insurance. No coverage is provided for loss caused by or resulting from: 1. Injury or Sickness arising out of or in the course of employment; or which is compensable under any Workers' Compensation or Occupational Disease Act or Law; 2. Declared or undeclared war; or act of war; 3. Expenses which are not ordered or under the written direction of a Physician; 4. Cosmetic surgery. This does not apply to: a. Reconstructive surgery incidental to or following surgery resulting from trauma, infection, or other diseases of the involved part; or b. [Reconstructive surgery because of a congenital disease or anomaly of a covered Dependent newborn or adopted infant; or] c. Reconstructive surgery on a non -diseased breast to restore and achieve symmetry between two breasts following a mastectomy. 5, Hearing examinations or hearing aids; 6. Vision services and supplies related to eye refractions or eye examinations, eyeglasses or contact lenses or prescriptions or fitting of eyeglasses other than for a disease process, and radial keraecomy, keratomileusis or excimer laser photo refractive keratectomy or similar type procedures or services; 7. Charges made by a health care provider if such provider is a member of the Covered Person's Immediate Family or is living with the Covered Person; 8. Any period of Custodial Care confinement in a Hospital or Skilled Nursing Facility; 9. Charges for Home Health Care Services, unless provided in lieu of a Hospital confinement. 10. The Covered Person's commission of a felony; 11. Charges in connection with manipulations of the musculoskeletal system, which includes manipulation of the muscles, joints, soft tissue, bone, spine, as well as traction and massage and applications of heat and cold; 12. The treatment of mental or nervous disorders, alcoholism, or any form of substance abuse, except as specifically provided; 13. Intentionally self-inflicted Injury or suicide attempt while sane or insane; 14. Dental care and treatment, except that required by Injury and rendered within 6 months of the Injury; 15. Treatment which is determined to be Experimental or Investigational. No benefits will be paid for any expense incurred after the date the policy terminates.) SHR-CERT-01 32 Rev [Dental Insurance Benefits Dental Expense Benefits If a Covered Person incurs expenses for a service on the "List of Covered Dental Procedures", such charges are covered to the extent that they: 1. Are Usual and Customary; 2. Constitute Necessary Treatment; and 3. Are incurred while insured for this benefit. We will pay, the scheduled benefit for such covered expenses which are in excess of the Deductible Amount. Payment is subject to the following: When a service or supply has an appropriate alternative that is in accordance with accepted standards of dental practice; the service or supply having the lesser charge shall be considered as being the Covered Charge; 2. The Maximum Amount Payable for each Covered Person will not exceed the applicable maximum stated in the Benefit Specifications; 3. Covered Charges for dental expenses will be considered to be incurred for: a. Appliances or a modification of appliances; on the date the master impression is made; b. All other charges; on the date service is rendered or a supply furnished. 4. Cash Deductible per Coverage Year: [$25] per Covered Person Benefit Limitations Coverage is not provided for services or supplies for which a charge is not customarily made in the absence of insurance. No coverage is provided for loss caused by or resulting from: 1. Injury arising out of or in the course of employment; or which is compensable under any Workers' Compensation or Occupational Disease Act or Law; 2. Declared or undeclared war; or act of war; 3. Intentionally self-inflicted Injury or suicide attempt while sane or insane; 4. A service furnished a Covered Person for: a. Cosmetic purposes, unless needed as a result of Injury. Facing on crowns, or pontics, posterior to the second bicuspid shall always be considered cosmetic; b. Dental care of a congenital or developmental malformation, unless benefits for Orthodontic services are specifically provided in the Benefit Specifications; SHR-CERT-01 33 Rev 5, Replacement of lost or stolen appliances; 6. Appliances, restorations, or procedures for the purpose of altering vertical dimension, restoring or maintaining occlusion, splinting, or replacing tooth structure lost as a result of abrasion or attrition, or treatment of disturbances of the temporomandibular joint; 7. A service not furnished by a Dentist, except: a. That performed by a licensed dental hygienist under a Dentist's supervision; and b. X-rays ordered by a Dentist; 8. Applicable Waiting Period: None SHR-CERT-01 34 I Rev List of Covered Dental Procedures — Plan [8121 The following is a complete list of dental procedures covered under the Dental Expense Benefit. Any procedure not listed is excluded. If one or more of the listed procedures would be appropriate according to customary dental practice, the Maximum Covered Charge will be the amount allowable for the lesser charge. Procedure Number Description of Services PREVENTIVE PROCEDURES — [$0] Deductible ORAL EXAMINATION 0120 Maximum Covered Charge Periodic oral examination (limited to 1 examination every 6 months) provided no other procedure is performed during the same visit 0140 Limited Oral evaluation/problem focused 0150 Comprehensive oral evaluation (limited to one examination per coverage year) [27.00] 1204 consecutive months) [12.00] 1351 Sealant, per tooth [16.00] SHR-CERT-01 35 Rev 9110 Emergency palliative treatment, per visit X-RAY AND PATHOLOGY (Except for injuries, covered charge includes examination and diagnosis). 0210 Entire denture series consisting of at least 14 films, including bitewings if necessary (limited to once every- 3 years) [40.00] 0220 Single film - Initial [7.00] 0230 Single film - each additional [7.00] 0240 Intra-oral occlusal view, maxillary or mandibular, each (limited to once every 36 consecutive months) [10.00] 0250 Superior or inferior maxillary, extra oral, 1 film [11.00] 0260 Extraoral - each additional [9.00] 0270 Bitewing - single film (limited to once every 6 months) [8.00] 0272 Bitewing films, 2 including examination (limited to once every 6 months) [12.00] 0274 - •itewing films, 4 including examination (lirnited to once every 6 months) [17.00] PROPHYLAXIS AND FLUORIDE APPLICATIONS 1110 Prophylaxis for individuals age 14 or over, treatments to include scaling and polishing (limited to one treatment every 6 months) 1120 Prophylaxis for children under age 14 (limited to one treatment every 6 months) 1203 Topical application of stannous fluoride, excluding prophylaxis, per treatment (limited to 1 treatment per 6 consecutive months for children under age 14) Topical application of fIoride/adult (limited to one treatment per 6 [17.00] [27.00] [38.00] [30.00] [20.00] [12.00] BASIC PROCEDURES- [$25] deductible applies to Basic Procedures, per person, per coverage year. AMALGAM RESTORATIONS — PRIMARY TEETH 2110 Cavities involving 1 surface [32.00] 2120 Cavities involving 2 surfaces [39.00] 2130 Cavities involving 3 surfaces [48.00] 2131 Cavities involving 4 or more surfaces [58.00] AMALGAM RESTORATIONS — PERMANENT TEETH 2140 Cavities involving 1 surface [35.00] 2150 Cavities involving 2 surfaces [45.00] 2160 Cavities involving 3 surfaces [56.00] 2161 Cavities involving 4 or more surfaces [64.00] SYNTHETIC RESTORATIONS 2210 Silicate cement - per restoration [32.00] 2330 Composite resin -- 1 surface, anterior [42.00] 2331 Composite resin — 2 surfaces, anterior [55.00] 2332 Composite resin — 3 surfaces, anterior [67.00] 2335 Composite resin — 4 or more surfaces, or involving incisal angle, anterior [69.00] 2336 Composite resin crown - anterior primary [77.00] 2380 Composite resin — 1 surface, posterior primary [36.00] 2381 Composite resin — 2 surfaces, posterior primary [62.00] 2382 Composite resin — 3 or more surfaces, posterior primary [73.00] 2385 Composite resin — 1 surface, posterior permanent [50.00] 2386 Composite resin — 2 surfaces, posterior permanent [68.00] 2387 Composite resin 3 or more surfaces, posterior permanent [85.00] 2951 , Pin retention, per tooth [12.00] SHR-CERT-01 36 Rev ORAL SURGERY (Includes local anesthesia and routine post -operative care). EXTRACTIONS 7110 Uncomplicated, single [39.00] 7120 Uncomplicated each additional tooth [35.00] 7130 Root recovery, exposed [46.00] 7210 Removal of Erupted Tooth [30.00] 7220 Removal of Impacted Tooth — Soft Tissue [45.00] 7230 Removal of Impacted Tooth — Partially Bony [70.00] 7240 Removal of Impacted Tooth — Completely Bony [85.00] 7241 Removal of Impacted Tooth — Completely Bony with Unusual Surgical Complications [85.00) 7250 Removal of Residual Tooth Roots [30.00] 7510 Incision and drainage of abscess 145.00) 9220 General Anesthesia [52.00] PERIODONTICS 4341 Periodontal scaling and root planing, per quadrant [72.001 4355 Full Mouth Debidgement to enable comprehensive periodontal evaluation and diagnosis [50.00] 4910 Periodontal maintenance procedures following active therapy, periodontal prophylovic [53.00] ENDODONTICS (excluding final restoration) 3220 Therapeutic Pulpotomy 120.00] 3310 Root Canal 1 — Anterior [125.00) 3320 Root Canal 2 — Bicuspid [135.00] 3330 Root Canal 3 — Molar [140.00] 3340 /Root Canal 4 — Molar [145.00]) SHR-CERT-01 37 Rev VII. Termination of Insurance The earliest of: 1. The date ending the last period for which You made any required premium contribution; 2. The date You enter the armed forces of any country; membership in the reserves is not deemed entry into the armed forces; 3. The date You are no longer a member of a class eligible for insurance; is the date on which Your insurance will terminate. The insurance of all Covered Persons will terminate immediately: 1. With respect to a coverage, on the date on which that coverage is canceled; 2. On the date of termination of the policy. Termination of participation with the Holder by an Employer shall be deemed termination of the policy with respect to such Employer. [The insurance of a covered Dependent will terminate on the earliest of: 1. The date Your insurance terminates; 2. The date he enters the armed forces of any country; membership in the reserves is not deemed entry into the armed forces; or 3. The date he ceases to be a Dependent as defined. However, if an unmarried insured Dependent child is: 1. Incapable of self-support due to mental retardation or physical handicap; and 2. Dependent upon You for support and maintenance; his insurance will not be terminated because of age. We will require due proof of the child's incapacity within 31 days after he reaches the termination age for children. The insurance for the child may be continued for as long as: 1. Th4 incapacity and dependency continues; and 2. The insurance remains in force for the Insured Person.] Extension of Benefits If a Covered Person is hospitalized when coverage terminates for any reason except nonpayment of premium, health insurance benefits shall continue at the same level for a period of [10] consecutive days during a single period of continuous hospitalization. SHR-CERT-01 38 Rev VIII. Conversion Privilege [Life Insurance 1. If the insurance, or any portion of it, for any Insured Person terminates because of his termination of membership in a class eligible for insurance under the policy this section 1. will apply. Such Insured Person is entitled to have an individual policy of life insurance issued to him, subject to the following conditions: a. The individual policy may not contain disability or other supplementary benefits; b. No evidence of insurability is needed; c. The amount of insurance may not exceed the amount terminated; d. The individual policy will be on the form We then issue to those Insured Persons whose insurance under the group policy was offered as a benefit of employment. The Insured Person, however, will have the option to have issued to him preliminary or interim term insurance. Such policy will not be issued for a period of longer than 1 year, e. Written application must be made to Us at Our Home Office within 31 days after the termination. Payment of the first premium must be made at the same time; f. The premium for the individual policy will be based on rates filed by Us for such policy, the attained age of the Insured Person and the amount of insurance. 2. If after the group policy has been in effect for a period of at least 5 years the insurance for any Insured Person terminates because the policy terminates this section 2. will apply. It will also apply if the policy is amended to make ineligible for insurance the class of which he is a member. If the Insured Person has been continuously insured under the policy for at least 3 years before this termination date, he is entitled to have an individual policy of life insurance issued to him. The same conditions specified in section 1. above will apply. The only exception is that the amount of the individual policy will not exceed the smaller of: a. The amount terminated under the policy. This amount will be reduced by the amount of any life insurance for which he is or becomes eligible under any group policy issued or reinstated within 31 days; and b. $2,000.00. 3. Ifaperson dies during the 31 day period within which he would have been entitled to have an individual policy issued to him and before any such policy becomes effective, the amount of life insurance to which he would have been entitled under the individual policy will be payable as a claim. The claim will be paid under the group policy, whether or not the application or payment of the first premium for the individual policy has been made. 4. The exercise of this privilege will be in lieu of all other benefits under the policy.] SHR-CERT-01 39 Rev [Health Insurance 1. The right to convert the medical insurance to conversion coverage is available to any Covered Person whose insurance under the policy ceases for any reason except: a. Termination of the policy; b. Termination of the class of Covered Persons; or c. Non-payment of the required premium. 2. The conversion coverage will be issued without proof of good health subject to the following: a. Written application must be made to Us at Our Home Office within 31 days after the insurance under the group policy ceases. Premium payment also must be made within the 31 day period. b. Our underwriting rules and standards with respect to overinsurance. c. The conversion coverage will be on the form We then issue to those Covered Persons whose insurance under the group policy was offered as a benefit of employment. d. The effective date of the conversion coverage will be the day following the date insurance under the group policy ceases.] [Conversion Privilege in Other Jurisdictions The jurisdiction where delivery of the conversion coverage is to be made controls the form We issue. The laws of the jurisdiction may require a special plan be provided or be available. If that is the case, We will either 1. Provide the coverage; or 2. Refer the person to the proper source for coverage.] SH R-CERT-01 40 Rev IX Transitional Coverage This provision applies to Individuals [and Dependents] who: 1. Were validly insured under the Holder's prior group health plan on the day before the Policy Date; 2. Were Totally Disabled on the Policy Date; and 3. Are unable to satisfy the provisions relating to "Effective Date Conditions" contained in the policy. This provision is not to be considered as negating any extension of benefits provided upon policy termination by the prior group health plan. A person to whom this provision applies will, even though Totally Disabled, be covered for medical care and treatment benefits under Our policy. The benefits under Our policy will be equal to the amount of the benefits, if any, that were provided under the prior plan. However, benefits which are payable under any extension of benefits of the prior plan will reduce any medical benefits otherwise payable under Our policy for the condition causing Total Disability. Such person's coverage will continue at the above described level until the earliest of: 1. The date he ceases to be Totally Disabled; 2. The date his insurance would otherwise terminate according to the provisions of Our policy; 3. The date he becomes insured under Our policy by satisfying the "Effective Date Conditions" provisions of Our policy; 4. With respect to an Individual who is Totally Disabled [and his Dependents), the end of 12 months from the Policy Date. If coverage terminates due to 2. or 4. above, the extension of benefits feature under Our policy will be applied at the benefit level of the prior plan. SHR-CERT-01 41 Rev X. Uniform Provisions The Group Policy is available for inspection at the Holder's office any time during regular business hours. Entire Contract; Changes The policy, the application of the Holder, the application of the Participating Employer, the applications of the Insured Persons, if any, and any attached papers form the entire contract between the parties. Arty statement made by the Holder or any Insured Person shall, in the absence of fraud, be considered a representation and not a warranty. No such statement shall be used in defense to a claim unless: 1. It is contained in a written application; and 2. A copy of such application has been furnished to the Holder or Insured Person, whomever made the statement. No such statement of the Holder, except a fraudulent statement, shall be used to void the policy after it has been in force for 2 years from its effective date. After the insurance of an Insured Person has been .in force for 2 years under the policy, no such statement of the Insured Person, except a fraudulent statement, shall be used to void the Insured Person's insurance or to deny or reduce a claim for loss incurred after such 2 year period. No one has the right to change any part of the policy or to waive any of its provisions unless the change is approved in writing on the policy by one of Our executive officers. Written Notice of Claim - Written notice of claim must be given to Us within 30 days after the loss begins. If notice cannot be reasonably given within that time, it must be given as soon as reasonably possible. The notice will be sufficient if it identifies the Insured Person and is sent to Us at Our Home Office or is given to Our agent. Claim Forms After the written notice of claim is received, claim forms will be furnished within 15 days; if they are not, the Insured Person will be considered to have met the requirements for written proof of Toss if We are sent written proof as described below. The proof must describe occurrence, extent and nature of the Toss. Written Proof of Loss The written proof of Toss must be sent to Us within 90 days after the date of loss in case of a claim for Accidental Death. For any other Toss it must be sent within 90 days after the end of a period for which We are liable. If it is not reasonably possible to give the proof within 90 days, a claim is not affected if the proof is sent as soon as reasonably possible. But, unless the Insured Person is legally incapacitated, written proof must be given within 1 year of the time it is otherwise required. SHR-CERT-01 42 Rev Time of Payment of Claims We will pay benefits due the Insured Person not more than 60 days after We receive due written proof of loss; -any loss for which the policy provides periodic payment will be paid monthly. Payment of Claims Benefits for loss of life will be payable in accordance with the beneficiary designation; if no such designation is in effect on the Insured Person's date of death, the Benefits will be payable as follows: 1. To his spouse, if living; 2. If not, in equal shares to his living children; 3. If there are none, in equal shares to his living parents; 4, If there are none, in equal shares to his living brothers and sisters; 5. If there are none, to his estate. (If any Benefit becomes payable to the Insured Person's estate, or to someone who is a minor or otherwise not competent to give a valid release, We may pay such Benefit up to $5,000.00 to any relative by blood, or connection by marriage of the Insured Person or beneficiary who is deemed by Us to be equitably entitled to it. Any such payment made in good faith shall fully discharge Us to the extent of such payment). Subject to the Insured Person's written direction to the contrary, all Benefits provided by the policy shall be payable to the Insured Person. In no case will We require that the service be rendered by a particular Hospital or person. Physical Examination (and Autopsy) We have the right to have a Physician examine a Covered Person at Our expense, as often as it is reasonably required while the claim is pending. We also have the right to have an autopsy performed at Our expense where it is not forbidden by law. Legal Actions No action t law or in equity can be brought until 80 days after the date written proof of loss has been given. No action can be brought after 3 years from the date written proof is required. SHR-CERT-01 43 Rev XL COBRA The following section contains information regarding the COBRA continuation of health coverage. It is included as an accommodation to Your Employer. It places no obligation upon The MEGA Life and Health Insurance Company, nor is The MEGA Life and Health Insurance Company liable for the content. Continuation of Coverage * Very Important Notice * Effective January 1, 1990, Public Law 99-272, Title X requiring that most employers sponsoring group health plans offer employees and their families the opportunity for a temporary extension of health coverage (called "continuation coverage") was amended to reflect the provisions indicated below. This notice is intended to inform You, in a summary fashion, of Your rights and obligations under the continuation coverage provisions of the law. Both You and Your spouse should take the time to read this notice carefully. If You are an employee, who is covered under this Plan, You have the right to choose this continuation coverage if You lose Your group health coverage because of a reduction in Your hours of employment or the termination of Your employment (for reasons other than gross misconduct on Your part) or if You are a retiree, for the reasons specified below. If you are the spouse of ari employee (or a retiree for reason 5. below) covered under this Plan, you have the right to choose continuation coverage for yourself if you lose group health coverage under this Plan for any of the following reasons: 1. The death of your spouse; 2. A termination of your spouse's employment (for reasons other than gross misconduct) or reduction in your spouse's hours of employment; 3. Divorce or legal separation from your spouse; - 4, Your spouse becomes covered by Medicare; or 5. Your spouse's Employer files for Chapter 11 reorganization. A Dependent child of an employee (or a retiree for reason 6. below) covered under this Plan has the right to continuation coverage if group health coverage is lost for any of the following 6 reasons: 1. The death of a parent; 2. The termination of a parents employment (for reasons other than gross misconduct) or reduction in a parent's hours of employment; 3_ Paents' divorce or legal separation; 4. A parent becomes covered by Medicare; 5. The Dependent ceases to be a "Dependent child" under this Plan; or 6. The parent's Employer files for Chapter 11 reorganization. Under this law, the employee or a family member has the responsibility to inform the Plan Administrator of this Plan of a divorce, legal separation, or a child losing Dependent status under this Plan within 60 days of the qualifying event. The employee or a family member also has the responsibility of notifying the Plan Administrator of the Social Security disability determination of any family member that was covered by the Plan, if the family member was disabled at any time during the first 60 days of continuation coverage. SHR-CERT-01 44 Rev Also, if You have changed marital status, or You or Your spouse have changed address, Please noti, jy the Plan Administrator, SHR-CERT-01 46 Rev THE MEGA LIFE AND HEALTH INSURANCE COMPANY 1331 W. Memorial Road, Suite 112 Oklahoma City, OK 73114 Holder: [XYZ Trust Company, Trustee for ABC Employers Trust] Policy Number: [12345] Policy Date: [January 1, 2002] Anniversary Date: [January 1, of each year.] We agree to insure certain Individuals and to pay the benefits provided by this policy in accordance with its provisions. This policy is issued in consideration of statements made in the application and the payment of premiums by the Holder. A copy of the signed application will be attached and made a part of this policy. This policy is effective on the Policy Date. The Policy Date will be the date of issue. The first Policy Year will end on the Anniversary Date shown above. Each Policy Year after that will end on the same date of each year. All periods will begin and end at 12:01 A.M. Standard Time at the Holder's main address. Signed for The MEGA Life and Health Insurance Company at [City, State, Date]. f4,4 AriffnAo•tea--- President Secretary Group Insurance Policy Renewable with the Consent of the Company SHR-POL-01 1 L Table of Contents Section Insuring Agreement Face Page Table of Contents I. Classification and Definition II. Additional Provisions III. Policy Content IV. SH R-POL-O'1 2 II. Classification and Definition All individuals in the following classes are eligible for insurance: As defined in each Employer's group certificate. AM individuals in the fdlowing classes are to be excluded from coverage: As defined in each Employer's group certificate. Contributory — Non -Contributory The Coverage provided under this policy will be on: 1. The contributory plan applies to each Class of Employee as defined in the Employer's group certificate. The Individual must apply for such insurance and agree to make required contributions; 2. The non-contributory plan applies to each Class of Employee as defined in the Employer's group certificate. No contribution is required from them toward the payment of premiums. SHR-POL-01 3 III. Additional Provisions Registry of Individuals The Holder will furnish Us with: w1 1. The names of all persons who are insured on the Policy Date; 2. The names of all persons who from time to time after the Policy Date become eligible for insurance; 3. The names of all Insured Persons whose eligibility for insurance ceases before this policy terminates; and 4. All data necessary to determine the premium for this policy. Premiums The premium rates as of the Policy Date, for the coverage provided, shall be as shown in the master application. All premiums are to be paid by the Holder to Us or to Our duly authorized agent. If a Covered Person's insurance: 1. Becomes effective; or 2. Changes in amount; other than on a premium due date, premium will be charged for that person from the next due date. If a Covered Person's insurance ceases other than on a premium due date, premium must be paid for that person up to the next due date. We have the right to change premium rates. Change may be made on the first policy anniversary or on any premium due date thereafter. Before any change is effective, however, We will give 60 days written notice of the change to the Holder. We also have the right to inspect the Holder's books and records as they relate to the insurance under this policy. This right may be exercised at reasonable times. Clerical error in keeping the records will not 1. Void insurance otherwise validly in force; nor 2. Continue insurance otherwise validly terminated. Upon discovery of a clerical error an equitable adjustment of premiums will be made. SHR-POL-01 4 Renewal of Policy The policy is issued as of the Policy Date specified on the face page. It continues in force for the period for which premium has b erl paid. The policy may be renewed for further consecutive periods by the payment of Osmium as stated in this policy. We have the right not to renew this policy- as of any premium due date. However, with respect to health insurance, we have the right not to renew this policy only for the following reasons: 1. Nonpayment of premiums by the Holder. 2. Fraud or material misrepresentation on the part of the Holder. 3. Violation of participation or contribution rules by the Holder. 4. We cease to market the product for which coverage was obtained. If We do not renew, We will give written notice to the Holder of such action at least 90 days prior to such date. Grace Period A grace period of 31 days will be allowed for the payment of premium after the first premium. During the grace period, this policy will be in force. If at least 60 days prior to the premium due date We send written notice to the Holder of Our intent not to renew this policy, the grace period will not apply to any period after the date the non -renewal is to be effective. If the Holder tells Us in writing that the policy will not be renewed, the grace period will not apply after the date the non -renewal is to be effective. If the premium is not paid by the end of the grace period, the policy will terminate on that date. The Holder will continue to be liable to Us for any unpaid premiums in addition to the premiums for the grace period. Termination of Policy We reserve the right to terminate the policy, or any coverage provided under the policy if less than 10% of the total number of Individuals eligible for such insurance are .insured under this policy. We may also terminate the policy if Tess than 50 such Individuals are insured. Any such termination shall be as of a premium due date. Written notice of any such termination will be mailed not Tess than 60 days prior to the date of termination to the address of the Holder as shown in Our records. Misstatement of Age If the age of a Covered Person is misstated, the amount of insurance will be the amount determined by the plan of insurance. The premium, however, will be adjusted so that the Holder will pay Us the actual premium called for at the true age of the Covered Person. SHR-POL-01 5 Modifications No one has the right to change any part of the policy or to waive any of its provisions unless the change is approved in writing_ The approval must be made by one of Our executive officers. Individual Ceftificate We will issue to the Holder for delivery to each Insured Person a certificate describing the insurance coverage and to whom payable. Conformity with State Statutes If on its effective date any provision of the policy is in conflict with the statutes of the state in which the policy was issued the provision is automatically amended to meet the minimum requirements of the statute. SHR-POL-tit 6 Its of Florida L )any dents. a by the folio\ lcludes adopte ste of stepchildren as red as a DePer arents. Children Provis ;d Children i as a Defender Ate ot birth. Col dCoverage ,d congenital def IV Policy Content The content of this Policy s Qontinued in the attached Exhibit(s) which are hereby mac part of the Policy issued to the PCYZ Trust Company, Trustee for ABC Employers Ti Policy Number 123451: Participating Employer Name: [DEF Company] Participating Employer Policy Number: [12345] Exhibit # Effective Date For All Classes Form Numbers) (1 1/1/2002 Employee Certificate SHR-CERT-01) and any amendments thereto. SHR-POL-01 7 taffed and equipped protect the health and Customary die the date of placeme lent to adopt such el red if such child is nc ecessary care and tr adoption. if timely n' rn child or child place liven, We may chargi ption. We will e birth of the child. V Ay notify Us if notice i I premium required to period shall be pa% )r daughter including ndicaPped will end or ability Benefit A employment which is Act or Law; iemnitY Benefit of employment which i se Actor Law; THE MEGA LIFE AND HEALTH INSURANCE COMPANY 1331 W. Memorial Road, Suite 112 Oklahoma City, OK 73114 .` Amendatory Rider This rider is attached to and made a part of the Certificate provided to residents of Fk Group Policy ST-0100 issued by The MEGA Life and Health Insurance Company. Florida requires the following additional benefits and/or provisions for its residents. The Certificate is hereby amended, solely with respect to residents of Florida, by the IV. Definitions The definition of "Child" is deleted and replaced with the following: "Child" includes Your natural children and those of Your spouse. It also includes ado children from the date of placement for the purposes of adoption or the date of birth r agreement to adopt such child was entered into prior to the date of birth, stepchildrer children provided: 1. They depend upon You for support; 2. They are domiciled with You; and 3. They have a parent --child relationship with You. If both parents of a Child are Insured Persons the Child will be considered as a Depe either parent. The Child may not be considered a Dependent of both parents. V. Conditions and Effective Date The Effective Date of Health Insurance for Newborn or Adopted Children provi`- deleted and replaced with the following: [Effective Date of Health Insurance for Newborn or Adopted Children A child born to a Covered Person will automatically become insured as a Depender Insurance. The effective date of insurance for the child will be the date of birth. Cove to the same extent as is provided for other covered dependent children. Coverage c coverage for Injury or Sickness, including: 1. The Necessary Care and Treatment of medically diagnosed congenital defe 2. Birth abnormalities; 3. Prematurity; SHR-RIDER-FL-01 1 eplaced with the followir 'cations, charges for dru ;ed by a licensed pharm ltitioner of the healing ar vered Expenses'subie Ind cleft palate for cove antal, speech therapy, as 1ysician. ent of a Coverede Persoi attend' etermined by medic ice with prevailing ,vered Person. e in keeping with preve nal qualified to provide ;onsultation with the Co\ ad at the most medicall Physician's office, outpat sary Treatment of osteo )sis; or therapy; or 3 Covered Person who: ly a licensed dentist, and ti ment in a Hospital or amb conditiorovedr a dio b evev� fife e ice has p could create significant or L Adelivery of any nece ssar ospita% or ambulatory surgi or surgery shall be conside a medical condition if left u lure involving bones or join standards, such procedure ► by congenital or develop 4. Transportation of the child to and from the nearest facility staffed and equi treatment of the child. Transport must a. Be by a licensed ambulance service; and b. Be certified by the attending Physician as necessary to protect the het of the child. Benefits for such transport will not be more than the Usual and Customary aggregate of $1,000.00; 5. Routine nursery care. With respect to an adopted child, coverage will be effective from the date of place purposes of adoption or from the date of birth if a written agreement to adopt suc entered into prior to the date of birth. Coverage will not be required if such child is Your residence following birth. Such coverage will include the necessary care ani medical conditions existing prior to the date of placement. ..You must notify Us within 31 days of the birth or placement for adoption. If timer given, We will not charge an additional premium for the newborn child or child ph' adoption for such 31-day notice period. If timely notice is not given, We may cha additional premium from the date of birth or placement for adoption. We will not for a newborn child due to Your failure to timely notify Us of the birth of the child. deny coverage for an adopted child due to Your failure to timely notify Us if notic 60 days of the birth or placement for adoption. Any additional premium required newborn or adopted child's coverage beyond the 31-day notice period shall be p manner as for other coverage under the policy. All liability with respect to a newborn child of a covered son or daughter indudint newborn children who are mentally retarded or physically handicapped will end c of: 1. The date the Insured Person's insurance terminates; 2. The date the newborn child is 18 months old.] VI. Benefit Descriptions — Life Insurance Benefit Limitation #1 is deleted. VI. Benefit Descriptions — Short Term Disability Benefit Benefit Limitation #1 is replaced with the following: 1. Injury or Sickness arising out of or in the course of employment which is Workers' Compensation or Occupational Disease Act or Law; VI. Benefit Descriptions — In -Hospital Indemnity Benefit Benefit Limitation #1 is replaced with the following: 1. Injury or Sickness arising out of or in the course of employment which is Workers' Compensation or Occupational Disease Act or Law; SHR-RIDER-FL--01 2 ires der any as not mice in The Otto Vi. Benefit Descriptions Health Insurance Items #9 and #14 under the List of Covered Expenses are replaced with the followin4 9. If a Prescription Benefit is shown in the Benefit Specifications, charges for drug medicines requiOng a written prescription and dispensed by a licensed pham a 14Charges for physical therapy given by a licensed practitioner of the healing art, within the scope of his license; The following additional benefits are added to the List of Covered Expenses, subject same terms and conditions: 18. Charges for the Necessary Treatment of cleft lip and deft palate for coverE under the age of 18. Coverage includes medical, dental, speech therapy, and ;uch nutrition services when prescribed by the treating Physician. 19. Charges for the inpatient medical care and treatment of a Covered Person mastectomy. The length of confinement shall be determined by the attendinc rats on the basis of Necessary Treatment in accordance with prevailing medics after the attending Physician's evaluation of the Covered Person. ring 20. Charges for outpatient postsurgical followup care in keeping with prevaili is, 18 standards by a licensed health care professional qualif1ed to provide l mastectomy care. The treating Physician, after consultation with the Cove! may choose that the outpatient care be provided at the most medically setting, which may include the Hospital, treating Physician's office, outpatier home of the Covered Person. ded at 21. Charges incurred for diagnosis and the Necessary Treatment of osteopo benefit is provided to a Covered Person who: a. is estrogen -deficient and at risk for osteoporosis; or b. Has a vertebral abnormality; or c. Is receiving long-term glucocorticoid (steroid) therapy; or arson d. Has primary hyperparathyroidism; or ,cal e. Has a family history of osteoporosis; or unless f. Has a similar high -risk for osteoporosis. 22. Charges for necessary dental care provided to a Covered Person who: a. is under 8 years of age and is determined by a licensed dentist, and the Physician, to require necessary dental treatment in a Hospital or ambula center due to a significantly complex dental condition or a developments which patient management in the dental office has proved to be ineffecti b. Has one or more medical conditions that would create significant or and risk for the Covered Person in the course of delivery of any necessary d treatment or surgery if not rendered in a Hospital or ambulatory surgical For purposes of this benefit, dental treatment or surgery shall be considers when the dental condition is likely to result in a medical condition if left untn 23. Charges for any diagnostic or surgical procedure involving bones or joints facial region if, under accepted medical standards, such procedures Necessary Treatment for conditions caused by congenital or developme disease or Injury. SHR-RIDER-FL-01 3 24. Charges for routine mammographic examinations for diagnostic screening procedures as follows: a. A baseline mammogram for covered women age 35 through 39; b. A mammogram every two years for Covered women age 40 to 49, unless recommended more frequently 15y her attending Physician; and c. A mammogram every year for covered women age 50 and over, or d. A mammogram once or more per year as recommended by a covered woman's attending Physician when the covered woman is at risk for breast cancer due to: i. A personal or family history of breast cancer; or ii. A history of biopsy -proven benign breast disease; or iii. Having a mother, sister, or daughter who has had breast cancer; or iv. Not giving birth before the age of 30, 25. Charges for a covered Dependent Child from the moment of birth to age 16 years. Such services shall be exempt from any Deductible provisions. "Child Health Supervision Services" means Physician -delivered or Physician - supervised services which shall include coverage for services delivered at the intervals and scope stated herein. Child Health Supervision Services shall include 18 visits at approximately the following age intervals: birth, 2 months, 4 months, 6 months, 9 months, 12 months, 15 months, 18 months, 2 years, 3 years, 4 years, 5 years, 6 years, 8 years, 10 years, 12 years, 14 years, and 16 years. Services to be covered at each visit include a history, physical examination, developmental assessment, anticipatory guidance and appropriate immunizations and laboratory tests, in keeping with prevailing medical standards. Benefits are limited to one visit payable to one provider for all of the services provided at each visit. The following is added to the Limitation for Pre -Existing Condition provision: Routine followup care to determine whether a breast cancer has recurred in a Covered Person who has been previously determined to be free of breast cancer does not constitute medical advice, diagnosis, care, or treatment for purposes of determining Pre -Existing Conditions unless evidence of breast cancer is found during or as a result of the followup care. Item #1 of the Benefit Limitations is replaced with the following: 1. Injury or Sickness arising out of or in the course of employment which is paid under any Workers' Compensation or Occupational Disease Act or Law; Item #11 of the Benefit Limitations is deleted. VI. Benefit Descriptions Dental Insurance Benefits The following is added: A Covered Person, or dentist acting for a Covered Person, who has had a claim denied as not Necessary Treatment or who has had a claim payment based on an alternate dental service in accordance with accepted dental standards for adequate and appropriate care, must be provided an opportunity for an appeal to Our licensed dentist who is responsible for the Necessary Treatment reviews under the plan or is a member of Our peer review group. The appeal may be by telephone, and Our dentist must respond within a reasonable time, not to exceed 15 business days. SHR-RIDER-FL-01 4 VII. Termination of Insurance The following is added: If a Covered Person is pregnant on either such date, benefits for the maternity expenses incurred will be continued for the period of tht pregnancy, provided such pregnancy commenced while the Covered Person was i sured under the policy. -40 The Extension of Benefits provision is deleted and replaced with the following: Extension of Benefits With respect to Health Insurance, if a Covered Person was Totally Disabled on the date coverage terminates, benefits will continue until: 1. 90 days elapse; 2. The date that the maximum amount of benefits have been paid; or 3. The date that the Covered Person ceases to be Totally Disabled; whichever first occurs. Only benefits for the Sickness or Injury causing the Total Disability are continued. No benefits are payable with respect to any other Sickness or Injury. With respect to Dental Insurance, benefits will continue for a Covered Person after the date coverage terminates if: 1. The course of treatment or dental procedures were recommended in writing and commenced, in connection with a specific Injury or Sickness incurred while the policy was in effect, by the attending Physician or dentist to the Covered Person while covered by the policy; 2. The dental procedures are for other than routine examinations, prophylaxis, X-rays, sealants, or orthodontic services; and 3. The dental procedures are performed within 90 days after the Covered Person's coverage ceased under the policy and the termination of coverage did not occur as a result of the Covered Person's termination of coverage. This extension of benefits terminates upon the earlier of: 1. The end of the 90-day period specified in #3 above; 2. The date the Covered Person becomes covered under a succeeding policy providing coverage or services for similar dental procedures, unless excluded by the succeeding policy through the use of an elimination period. With respect to Life Insurance, if a Covered Person: 1. Is Totally Disabled on the date of termination of the policy; 2. Had become Totally Disabled while insured under the policy; We will continue such Covered Person's Life Insurance during the continuance of the Total Disability for a period of 12 months from the date the insurance would otherwise have terminated. This will be without premium charge. The amount of insurance to be continued will be: - 1. For the Insured Person: the amount in force on the date of termination, subject to any reduction for age or retirement; and 2. For the Dependent: the amount in force on the date of termination. SHR-RIDER-FL-01 5 VIII. Conversion Privilege — Life Insurance Item #2.b. is replaced with $10,000EO ?. V111. Conversion Privilege — Heai3h4insurance The Health Insurance Conversion Privilege is replaced by the following: 1. The right to convert any hospital, surgical and medical insurance provided under the policy to conversion coverage is available to an Insured Person who has been continuously insured under the group policy, or under any group policy which it replaces, for at least 3 months and whose insurance under the policy ceases for any reason except a. Termination of the policy with replacement by similar medical coverage within 31 days; b. Termination of the class of Insured Persons with replacement by similar medical coverage within 31 days; c. Non-payment of the required premium. The conversion coverage will cover the Insured Person and his insured Dependents. If the Insured Person's coverage would continue after retirement, and he is not eligible for Medicare, he has the option of: a. Continuing his group coverage; or b. Receiving the conversion coverage. 2. The right to convert any hospital, surgical and medical insurance provided under the policy to conversion coverage is also available to: a. An insured spouse who ceases to be a Dependent due to: 1. Death of the Insured Person; 2. Annulment or dissolution of marriage; or 3. Ceasing to be a qualified family member. The conversion coverage will cover the spouse and the insured Dependent children whose insurance ceases; b. An insured child who ceases to be a Covered Person and who is not covered under conversion coverage. 3. The conversion coverage will provide coverage not Tess than that required by law. 4. The conversion coverage will be issued without proof of good health subject to the following: a. Written application must be made to Us at Our Home Office within 63 days after insurance under the group policy ceases. Premium payment must also be made within the 63 day period; b. The conversion coverage will be on the form We then issue to those Covered Persons whose insurance under the group policy was offered as a benefit of employment; c. The effective date of coverage will be the day following the date insurance under the group policy ceases. SHR-RIDER-FL-01 6 VII1. Conversion Privilege in Other Jurisdictions This provision is deleted. X. Uniform Provisions l The Time of Payment of Claims provision is replaced with the following: We Will pay benefits due the Insured Person as soon as We receive due written proof of loss; any Toss for which the policy provides periodic payment will be paid monthly. The Legal Actions provision is replaced with the following: No action at law or in equity can be brought until 60 days after the date -written proof of loss has been given. No action can be brought after 5 years from the date written proof is required. The Policy is hereby amended by the following_ III. Additional Provisions The Grace Period provision is replaced with the following: This policy has a 31 day grace period. This provision means that if a renewal premium is not paid on or before the date it is due, it may be paid during the following grace period. The grace period will not apply if, at least 30 days before the premium due date, We have delivered or mailed to the Holder's last address shown in Our records written notice of Our intent not to renew this policy. During the grace period, the policy will stay in force. If the premium is not paid by the end of the grace period, the policy will terminate on that date. All provisions, definitions, limitations and conditions of the Policy and Certificate which are not inconsistent with these benefits and provisions apply to them. For The MEGA Life and Health Insurance Company: cr41- President Secretary SHR-RIDER-FL-01 7 RFP Number: Commodity Codes: Commbdity Title: Type of Purchase: M/WBE Set -Aside: Sr. Buyer: Buyer Fax: E-Mail Address: Issue Date: Voluntary Pre -Proposal: Bid Bond: Day/Date: Time: Location/Mail Address: Directions: 1t City of Miami Request for Proposals RFP Purchasing Department Glenn Marcos, Director Miami Riverside Center 444 SW 2nd Avenue, 66' Floor Miami, Florida 33130 Web Site Address: http://ci.miami.fl.us/ Proposal Data 03-04-004 918-69; 94&-42; 953-48; 953-63; 962-47 Group Health Benefits for Part -Time Employees ONE (I-) YEAR WITH OTR FOR THREE (3) ADDITIONAL YEARS N/A Pamela Burns, CPPB (305) 416-1925 pburns@ci.miami.fl.us November 14, 2003 N/A NO Performance Bond: N / A Deadline For Request Of Additional Information/Clarification: 11/24/03 Proposal Submission Deadline MONDAY, DECEMBER 8, 2003 2:00 PM Office of the City Clerk City Hall, 1" Floor 3500 Pan American Drive Miami, Florida 33133-5504 FROM THE NORTH: 1-95 SOUTH UNTIL IT TURNS INTO US1. US1 SOUTH TO 27TH AVE., TURN LEFT, PROCEED SOUTH TO SO, BAYSHORE DR. (3RD TRAFFIC LIGHT), TURN LEFT, 1 BLOCK TURN RIGHT ON PAN AMERICAN DR. CITY HALL IS AT THE END OF PAN AMERICAN DR. PARKING IS ON RIGHT. FROM THE SOUTH: US1 NORTH TO 27TH AVENUE, TURN RIGHT, PROCEED SOUTH TO SO. BAYSHORE DR. (3RD TRAFFIC TIGHT), TURN LEFT, I BLOCK TURN RIGHT ON PAN AMERICAN DR CITY HALL IS AT THE END OF PAN AMERICAN DR PARKING IS ON RIGHT. RFP Content Sections 1.0 Introduction to Request for Proposals 2.0 Specifications/Scope of Work describing what is needed 3.0 General Terms and Conditions that are general in scope 4.0 Special Provisions of.Proposed Contract 5.0 Instructions for Submitting Proposal and Evaluation Criteria for this RFP 6.0 Response forms and Check List to be completed and submitted with Proposal Sealed written Proposals must be received by the City of Miami, City Clerk's Office, no later than the date, time and at the location indicated above for the Proposal Submission. Submittal of Response by fax is not acceptable. Ten (10) copies of your Proposal and response forms must be returned to the City or your Proposal may be disqualified. NOTE: This RFP does not constitute an order for the goods or services specified. The number of copies requested in this RFP together with completed Response Forms must be returned. CONE OF SILENCE ORDINANCE IS APPLICABLE TO THIS SOLICITATION. City of Miami, Florida Group Health Benefits for Part time Employees RFP 03-04-004 4 PUBLIC NOTICE Sealed Proposals will be received by the City of Miami City Clerk at her office located at City Hall, First Floor, 3500 Pan American Drive, Miami, Fla. 33133 for the following: RFP No. 03-04-004: The City of Miami ("City") is seeking Proposals from qualified and experienced sources to establish a term contract for Group Health Benefits for part-time City employees, for the Department of Risk Management. ISSUE DATE: Friday, November 14, 2003 Deadline for Request of Additional Information: Monday, November 24, 2003 at 5:00 PM SUBMISSION DATE: Monday, December 8, 2003 at 2:00 PM This Request for Proposals (RFP) is available from the City's website at http://www.ci.miami.fl.us/Procurement/bid.aso or the City's Purchasing Department, 444 S.W. 2 Avenue, Sixth Floor, Miami, Florida 33130 The telephone number is (305) 416-1906 or (305) 416- 1922. 2 City of Miami, Florida Group Health Benefits for Part time Employees RFP 03-04-004 1.0. INTRODUCTION TO REQUE T VOR PROPOSALS 1.1. -.Invitation Thank you for your interest in this Request for Proposal ("RFP") process. The City of Miami ("City"), through its Purchasing Department invites responses ("Proposals") which offer to provide the services described in greater detail in Section 2.0. 1.2. Term of Contract The Proposer selected to provide the services requested herein ("the Successful Proposer") shall be required to execute a contract ("Contract") with the City, which shall include, but not be limited to, the following terms: A. The initial term of the Contract shall be for two (2) years. B. The City shall have the option to extend the Contract for three (3) additional one (1) year periods, at its sole discretion. Successful Proposer will be given at least thirty (30) days prior written notice. C. Extension of the term of the Contract beyond the initial period is an option of the City to be exercised in its sole discretion and does not confer any rights upon the Successful Proposer. 1.3. Business Objective The City, a municipal corporation of the State of Florida, is seeking the services of qualified and experienced sources to establish a term contract to provide group health benefits to part-time City employees. 1.4. Deadline for Receipt of Request for Additional Information / Clarification Pursuant to the Cone of Silence, any request for additional information or clarification must be received in writing no later than 5:00 p.m. on Monday, November 24, 2003. Proposers may fax or mail their requests to the attention of Pamela Bums CPPB, Sr. Procurement Contracts Officer, at the City's Department of Purchasing, 444 S.W. 2"d Avenue, 6th Floor, Miami, Florida 33130. The facsimile number is (305) 416-1925 or email: pburns@ci.miami.fl.us. This RFP is subject to the City's "Cone of Silence" in accordance with Section 18-74 of the City's Ordinance No. 12271. 1.5. Cone of Silence Pursuant to Section 18-74 of the City's Ordinance No. 12271, a "Cone of Silence" is imposed upon each RFP, RFQ, RFLI, or IFB after advertisement and terminates at the time the City Manager issues a written recommendation to the Miami City Commission. The Cone of Silence shall be applicable only to Contracts for the provision of goods and services and public works or improvements for amounts greater than $200,000. The Cone of Silence_, prohibits any communication regarding RFPs, RFQs, RFLI or IFB .(bids) between, among others: • Potential vendors, service providers, bidders, lobbyists or consultants and the City's professional staff including, but not limited to, the City Manager and the City Manager's staff, the Mayor, City Commissioners, or their respective staffs; 3 Group Health Benefits for Part time Employees RFP 03-04-004 City of Miami, Florida • The Mayor, City Commissioners or tl it respective staffs and the City's professional staff including, but not limited to, the City Manager and the City Manager's staff; • Potential vendors, service providers, bidders, lobbyist or consultants, any member of the City's professional staff, the Mayor, City Commissioners or their respective staffs and any member of the respective selection/evaluation committee The provision does not apply to, among other communications: • Oral communications with the City purchasing staff regarding Minority/Women Business Enterprise (M/WBE) and local vendor outreach programs; Communication is limited strictly to matters of process or procedure already contained in the solicitation document; • The provisions of the Cone of Silence do not apply to oral communications at duly noticed site visits/inspections, pre -proposal or pre -bid conferences, oral presentations before selection/evaluation committees, contract negotiations during any duly noticed public meeting, or public presentations made to the Miami City Commission during a duly noticed public meeting; or • Communications in writing or by email at any time with any City employee, official or member of the City Commission unless specifically prohibited by the applicable RFP, RFQ or bid documents. • Communications in connection with the collection of -industry comments or the performance of market research regarding a particular RFP, RFQ, RFLI or IFB by City Purchasing staff. Proposers or bidders must file a copy of any written communications with the Office of the City Clerk, which shall be made available to any person upon request. The City shall respond in writing and file a copy with the Office of the City Clerk, which shall be made available to any person upon request. Written communications may be in the form of e-mail, with a copy to the Office of the City Clerk at icerrato@ci.miami.fl.us. In addition to any other penalties provided by law, violation of the Coin of Silence by any proposer or bidder shall render any award voidable. A violation by a particular bidder, proposer, offeror, Respondent, lobbyist or consultant shall subject same to potential debarment pursuant to the City Code. Any person having personal knowledge of a violation of these provisions shall report such violation to the State Attorney and/or may file a complaint with the Ethics Commission. Proposers or bidders should reference Section 18-74 of the City of Miami Code for further clarification. This language is only a summary of the key provisions of the Cone of Silence. Please review City of Miami Ordinance No. 12271 for a complete and thorough description of the Cone of Silence. You may contact the City Clerk at 305-250-5360, to obtain a copy of same. 1.6. Clarification Requests for additional information or clarifications must be made in writing and received by the Senior Buyer specified on the cover sheet of this RFP, in accordance with the deadline for receipt of questions specified in the RFP (see Section 1.4) and the Cone of Silence (see Section 1.5). The 4 City of Miami, Florida Group Health Benefits for Part time Employees RFP 03-04-004 request must contain the RFP number and title Proposer's name, name of proposer's contact person, address, phone number, and facsimile *Aber. Electronic facsimile requesting additional information will be received by the Sr. Buyer for this RFP at the fax number specified on the cover sheet of this RFP. Facsimiles must have a cover sheet which includes, at a minimum, the Proposer's name, name of Proposer's contact person, address, number of pages transmitted, phone number, facsimile number, and RFP number and title. The City will issue responses to inquiries and any other corrections or amendments it deems necessary in written addenda issued prior to the Proposal Submission Date. Proposers should not rely on any representations, statements or explanations other than those made in this RFP or in any written addendum to this RIP. Where there appears to be conflict between the RFP and any addenda issued, the last addendum issued shall prevail. 1.7. Award of Contract The opportunity to enter into the Contract shall be afforded to the Proposer whose Proposal is determined to be the most advantageous to the City and in the City's best interests, taking into consideration fees and other evaluation factors set forth in the RFP. 1.8. Contract Execution Contract will be negotiated and executed between the Successful Proposer and the City. 1.10. Unauthorized Work The Successful Proposer shall not begin work until a City purchase order ("Purchase Order") has been issued. The Purchase Order(s) shall specify the price and period of time allotted for the completion of the work. 1.11. Instructions Careful attention must be given to all requested items contained in this RFP. Proposers are invited to submit Proposals in accordance with the requirements of this RFP. Please read the entire solicitation before submitting a Proposal. Proposers shall make the necessary entry in all blanks provided for the responses. The entire set of documents constitutes the RFP. The Proposer must return these documents with all information necessary for the City to properly analyze Proposer's response in total and in the same order in which it was issued. Proposer's notes, exceptions, and comments may be rendered on an attachment, provided the same format of this RFP text is followed. All Proposals shall be returned in a sealed envelope with the RFP number and opening date clearly stated on the outside of the envelope. Proposers must provide a response to each requirement of the RFP. Proposals should be prepared in a concise manner with an emphasis on completeness and clarity. 1.12. Changes / Alterations Proposer may change or withdraw a Proposal at any time prior to Proposal submission deadline; however, no oral modifications will be allowed. 5 City of Miami, Florida Group Health Benefits for Part time Employees RFP 03-04-004 1.13. Assignment of Contract Successful Proposer shall not assign, transfee or subcontract, at any time during the term of the Contract, or any part of his/er operations, or assign any portion or part of the Contract, except under and -by virtue of written permission granted by the City through the proper officials, which may be withheld or conditioned, in the City's sole discretion. 1.14. Sub -Contractor A Sub -Contractor is an individual or firm contracted by the Proposer or-Proposer's firm to assist in the performance of services required under this RFP. A Sub -Contractor shall be paid through Proposer or Proposer's firm and not paid directly by the City. Sub -Contractors are allowed by the City in the performance of -the services delineated within this RFP. Proposer must clearly reflect in its Proposal any Sub -Contractors to be utilized in the performance of required services. The City retains the right to accept or reject any Sub -Contractors proposed in the response of Proposer or prior to contract execution. Any and all liabilities regarding the use of Sub -Contractors shall be borne solely -by the Successful Proposer and insurance for each Sub -contractor must be maintained in good standing and approved by the City throughout the duration of the Contract. Neither Successful Proposer nor any of its Sub -Contractors are considered to be employees of the City. Failure to list all Sub -Contractors and provide the required information may disqualify any proposed Sub -Contractors from performing work under this RFP. Proposers shall include in their Proposals the requested Sub -Contractor information and include all relevant information required of the Proposer. In addition, within five (5) working days after the identification of the award to the Successful Proposer, the Successful Proposer shall provide a list confirming the Sub -Contractors that it intends to utilize in the Contract, if applicable. The list shall include, at a minimum, the name, location of the place of business for each Sub -Contractor, the services Sub -Contractor will provide relative to any contract that may result from this RFP, any applicable licenses, references, ownership, and other information required of Proposer. 1.15. Discrepancies, Errors, and Omissions Any discrepancies, errors, or ambiguities in the RFP or addenda (if any) should be reported in writing to the City's Purchasing Department. Should it be necessary, a written addendum will be incorporated to the RFP. The City will not be responsible for anyoral instructions, clarifications, or other communications. 1.16. Disqualification The City reserves the right to disqualify Proposals before or after the submission date, upon evidence of collusion with intent to defraud or other illegal practices on the part of the Proposer. It also reserves the right to waive any immaterial defect or informality in any Proposals; to reject any or all Proposals in whole or in part, or to reissue a Request for Proposals. 1.17. Proposal Receipt Sealed Proposals will be accepted in accordance with the instructions detailed on the cover of this RFP. After that date and time, Proposals will no longer be accepted. The Proposer shall file all documents necessary to support its Proposal and shall include them with its Proposal. Proposers shall be responsible for the actual delivery of Proposals during business hours to the exact address indicated 6 City of Miami, Florida Group Heatfh Benefits for Part time Employees RFP 03-04-004 on the cover and in the RFP. Proposals that are not received by the City Clerk's Office by the deadline established in the RFP shall not be accepted or, tohlidered by the City. Ills 1 1.18,, Capital Expenditures The Proposer understands that any capital expenditures that the Proposer makes, in order to perform the services required by the City in this RFP, is a business risk which the Proposer may include in its proposed price. The City, however, is not and shall not pay or reimburse any capital expenditures or any other expenses; incurred by any Proposer in anticipation neither of a Contract award nor to maintain the approved status of the Proposer if a Contract is awarded. 1.19. RFP Process Milestones The anticipated schedule for this RFP and subsequent Contract is as follows. All dates are tentative and subject to change. > RFP available for distribution > Due date for Questions, ➢ Proposal Due Date ➢ Evaluation of Proposers by Evaluation Committee > Recommendation from Evaluation Committee to City Manager > Recommendation from the City Manager to the City Commission > City Commission Approval and authorization to execute Contract November 14, 2003 November 24, 2003 December 8, 2003 December 10, 2003 December 12, 2003 December 15, 2003 January 8, 2004 7 City of Miami, Florida Group Health Benefits for Part time Employees RFP 03-04-004 2.0. SPECIFICATIONS / SCOPE OF WORK 4E 2.1 Background The city is seeking to obtain a qualified and experienced health care provider to provide an affordable Group Health Benefits Program ("Program") for the City's part time employees. The City strives to maintain quality in their operations by implementing a new Health Benefits Program to approximately 300-500 part time employees working no more than 40 hours and temporary employees working 40 hours for more than 1 year. A census of the possible eligible employees is included with this RFP. This Plan is being created for non -benefited employees to use as their "core" Plan if/until employees are eligible for full-time permanent Plan. See attached census. The Successful - Proposer must offer the City a complete management of the Program, from enrollment, utilization of managed care networks, billing and payments, regardless of enrollment. The City proposes to only provide the Successful Proposer with employee contributions from those participating employees, and the Successful Proposer will be required to administer the entire Program. Premiums must be designed to be very reasonable. The City will contribute towards a portion of the employee's single coverage. It is anticipated the Successful Proposer will provide preventative health coverage, at nominal cost, to said part time employees. In order to keep premiums low, the plan should not be structured to provide catastrophic coverage. Coverage and network should be designed to be easily accessible to give Plan participants help with common, everyday medical expenses. Health benefit coverage for its regular City employees is provided at this time by Cigna. No coverage for its part time City employees is included in the current health insurance plan for its full- time employees. 2.2 Overall Scope of Services The following represent minimum services be provided as they apply to the Plan of benefits outlined above for part time City employees. The Successful Proposer shall: 1. Provide various Levels of the Plan for the employee and/or family, based upon cost and service(s) offered, and allow the part time employee(s) make a choice based upon Level off Service and cost, that which is in his/her best interest. 2. Offer no waiting period or be required to provide medical evidence of insurability prior to enrollment. 3. Require no minimum nuniber of _hours worked for eligibility or minimum number of employee participation. 4. Provide low health premiums to each enrolled part time City employee. 5. Provide a "self -bill" Program instead of billing statements. 6. Provide free COBRA Notification and premium collection. 8 City of Miami, Florida Group Health Benefits for Part time Employees RFP 03-04-004 7. Provide an Enrollment Center for direct communication to eligible employees. 8. Provide all premium/fee accounting services necessary to administer the Plan, and any banking charges that may apply, in addition to any other related costs to administer said Plan. 9. Provide booklets or booklet certificates, approved by the City, in sufficient quantity for all potential Plan participants and reprint as required by the City. Booklets or certificates are to be sent directly to insured's homes. 10. Provide applicable network directories in sufficient quantity for all potential Plan participants -and reprint as required by the City. Directories are to be sent to insured's homes during initial enrollment period and at applicable periods thereafter. 11. Provide appropriate I.D. Cards as specified and approved by the City. 12. Provide all related enrollment materials to insured's homes. 13. Provide an 800 phone number as well as dedicated representatives (for long distance calls) for claims service and plan information and related customer services. 14. Provide technical/sales staff, as may be required, for: initial enrollment, open enrollment, claim resolution and plan information and interpretation and costing of alternative benefits from time to time. 15. Provide EOBs which are to be sent to the employee's home. 16. Provide the City and its agent with paid claims and premium reports on a quarterly basis and with a complete financial analysis for the plan year within four (4) months after the end of the Plan year. 17. Provide complete COBRAIIIPAA administration, including certification of coverage, under the City 's plans according to the applicable Federal regulations. 18. Provide a minimum guarantee premium cost per part time employee for a minimum of twelve (12) months. 19. Provide upon request, City's logo to appear on various printed materials. Successful Proposer must agree to do this at no additional cost and must ensure that logo placement and color requirements are met, as applicable. 9 City of Miami, Florida Group Health Benefits for Part time Employees RFP 03-04-004 3.0. GENERAL TERMS AND CONDITIONS 3.1. Acceptance/Rejection w; The City reserves the right to accept or reject any or all Proposals or to select the Proposer that, in the opinion of the City, will be in the best interest of and/or the most advantageous to the City. The City also reserves the right to reject the Proposal of any Proposer who has previously failed to properly perform under the terms and conditions of a contract, to deliver on time contracts of a similar nature, and who is not in a position to perform the requirements defined in this RFP. The City reserves the right to waive any irregularities and technicalities and may, at its discretion, withdraw and/or re -advertise the RFP. 3.2. City Not Liable -for Delays It is further expressly agreed that in no event shall the City be liable for, or responsible to, the Proposer, any Sub -Contractor, or to any other person for, or on account of, any stoppages or delay in the work herein provided for by injunction or other legal or equitable proceedings or on account of any delay for any cause over which the City has no control. 3.3. Contract Award and City's Rights The Proposals will be evaluated by an Evaluation Committee ("Committee") appointed by the City Manager, comprised of appropriate City staff and members of the community, as deemed necessary, with the appropriate technical expertise and/or knowledge. The Committee shall evaluate each Proposal based upon the evaluation criteria established herein (the "Evaluation Criteria"). A Proposer may receive the maximum number of available points or a portion of this score depending on the merit of its Proposal, as evaluated by the Committee. The Committee reserves the right, in its sole discretion, to request one (1) or more Proposers to make oral presentations before the Committee as part of the evaluation process. Such presentations/interviews provide the Proposer with an opportunity to clarify the proposal and to ensure a mutual understanding of its content. The presentation may be scheduled at the convenience of the Evaluation Committee and shall be recorded. The Committee reserves the right to rank the Proposals and shall submit its recommendation to the City Manager for acceptance. The City Manager shall make his recommendation to the City Commission requesting the authorization to negotiate with the recommended Proposer. No Proposer shall have any rights against the City arising from such negotiations or termination thereof. The City reserves the. right to enter into Contract negotiations with the first ranked Proposer. If the City and the Proposer cannot negotiate a Contract, the City may terminate said negotiations and begin negotiations with another Proposer. This process may continue until a Contract acceptable to the City has been executed or all Proposals are rejected. The City reserves the right to negotiate with each responsible and responsive Proposer. No Proposer shall have any rights against the City arising from such negotiations or termination thereof. 10 City of Miami, Florida Group Health Benefits for Part time Employees RFP 03-04-004 The Proposer(s) shall acquire no vested rights by virtue the Evaluation Committee's recommendation. No rights at all shall accrij tko the benefit of the Successful Proposer until the Contract is executed by both parties. 40. While the City Commission may direct that the City negotiate a Contract with a Proposer(s), said Contract may be conditional on the subsequent submission of other documents within the time and in the manner specified in the contract. The final decision to award the Contract shall be made by the City Comniission. The City shall prepare and present the Contract for execution by the Successful Proposer. The City reserves the right to reject any or all Proposals, in whole or in part, and/or make award to one or more Proposers, whichever is deemed to be in the City's best interests. The City also reserves the right to waive any informalities, irregularities and technicalities in procedure at its sole discretion. 3.4. Cost Incurred By Proposers All expenses involved with the preparation and submission of Proposals to the City, or any work performed in connection therewith shall be borne by the Proposer. 3.5. Legal Requirements This RFP is subject to all applicable federal, state, county and local laws, ordinances, rules and regulations that in any manner affect any and all of the services covered herein. Lack of knowledge by the Proposer shall in no way be cause for relief from responsibility. 3.6. Minority / Women Business Enterprise (MIWBE) Program Ordinance No. 10062, as amended, entitled the Minority and Women Business Affairs and Procurement Ordinance of the City of Miami, Florida sets forth "...a goal of awarding at least 51 percent of the City's total annual dollar volume of all expenditures for all goods and services, to Black, Hispanic and Women minority business enterprises on an equal basis." A minority business enterprise is defined as a business firm "...in which at least 51 percent of said enterprise is owned by Blacks, Hispanics, or Women and whose management and daily business operations are controlled by one or more Blacks, Hispanics or Women." To achieve the goal established by Ordinance 10062, vendors doing business with the City are encouraged to include minority firms as participants in their Proposals. Acceptable ways for M/WBE and minority participation in this Proposal are: 1. Proposers certified by the City or State of Florida prior to Proposal submission. 2. Proposers, including sub -consultants certified by Miami -Dade County Public Schools or Miami -Dade County as M/WBE prior to Proposal submission, and certified by the City prior to the evaluation of Proposals by the Evaluation Committee. 3. Proposers who have key professional staff members who are Blacks, Hispanics and/or Women assigned to key positions for this engagement. 11 City of Miami, Florida Group Health Benefits for Part time Employees RFP 03-04-004 Failure to meet any of the above shall deem the Proposer ineligible for consideration as a M/WBE. 1` For the purposes of this RFP, a certified M/WBE is one which has been certified by the City of Miami or the State of Florida as a Black, Female, or Hispanic business enterprise. Entities which are M/WBE certified by the Miami -Dade County Public Schools or Miami -Dade County must be certified prior to Proposal submission, and must be certified as an M/WBE by the City prior to evaluation of Proposal by the Evaluation Committee. Proposers may contact the City Clerk's Office for copies of Ordinance No. 10062 and amendments. The Purchasing -Department will provide the necessary forms and instructions upon request. Please contact the M/WBE Supervisor, at (305) 416-1921. Each Proposer should also submit along with the Proposal an Affirmative Action Policy (AAP). 3.7. Local Preference City Ordinance No. 12271, states that the City Commission may offer to a responsible and responsive bidder, who maintains a Local Office, the opportunity of accepting a bid at the low bid amount, if the original bid amount submitted' by the local vendor is not more than ten percent (10%) in excess of the lowest other responsible and responsive bidder. Local preference regarding this RFP will be considered during the evaluation process. 3.8. Non -Appropriation of Funds In the event no funds or insufficient funds are appropriated and budgeted or funding is otherwise unavailable in any fiscal period for payments due under the Contract, then the City, upon written notice to the Consultant or his/her assignee of such occurrence, shall have the unqualified right to terminate the Contract without any penalty or expense to the City. 3.9. Occupational License Requirement Any Proposer with a business location in the City, who submits a Proposal under this RFP, shall meet the City's Occupational License Tax requirements in,accordance with Chapter 31.1, Article i of the City Charter. Proposers with a business location outside the City shall meet their local Occupational License Tax requirements. A copy of the license must be submitted with the Proposal; however, the City may at its sole option and in its best interest allow the Proposer to supply the license to the City during the evaluation period, but prior to award. 3.10. Payment Payments to the Successful Proposer shall be made in arrears, and based on work performed to the satisfaction of the City. No advance payments will be made at any time. Payment shall be made after delivery, within 45 days of receipt of an invoice for services/goods and pursuant to Florida Statute 218.74 and other applicable laws. 12 City of Miami, Florida Group Health Benefits for Part time Employees RFP 03-04-004 3,11. One Proposal Only one (1) Proposal from an individual, f' iii, partnership, corporation or joint venture will be considered in response to thisPRFP. 3.12. Proposer Minimum Qualifications Proposers shall satisfy each of the following requirements cited below. Failure to do so will result in the Proposal being deemed non -responsive. Proposer shall: A. Properly licensed to conduct business in the State of Florida. B. Shall have been providing Employee Health Benefit Services for at least two (2) years; preferably to at least two (2) similar size entities with similar scope of service. C. Current NCQA Accreditation Rating of Commendable or higher for Commercial HMO/POS business combined, D. AM Best rating of A or A+ and financial size category of X (ten) or higher and State of Florida Department of Insurance letter stating you are meeting current State of Florida Reserve Factors. E. Proposer shall have no record of judgments, pending lawsuits against the City or criminal activities involving moral turpitude and not have any conflicts of interest that have not been waived by the City Commission. F. Neither Proposer nor any principal, officer, or stockholder of Proposer shall be in arrears or in default of any debt or contract involving the City, (as a party to a contract, or otherwise); nor have failed to perform faithfully on any previous contract with the City. 3.13. On-line Vendor Registration It is the policy of the City that all prospective Proposers register on-line at http://www.ci.miami.fl.us/procurement, click on the link, Vendor Registration, fill out all required fields, and indicate the commodities/services which prospective Proposer can regularly supply to the City for bid / RFP notification purposes sent by the City to registered prospective Proposer via email or facsimile transmission, or both. Prospective Proposer who have already registered previously are not required to re -register. Unless, prospective Proposer has to update its information concerning changes such as ownership, new address, telephone number, fax, commodities, etc. Prospective Proposer can access its Vendor Profile by selecting the link; modify profile, and entering its assigned User ID and Password. All prospective Proposers should register on-line, regardless if Proposer submits a Bid or the "Statement of No Bid Form". The City will make its best effort to source all registered vendor with the related commodity or service of future bid/RFP solicitations and send bid/RFP notification via the email or facsimile, or both. Bid/RFP Notification sent via e-mail to prospective Proposer will contain a link of the solicitation to download the document, and the entire document will be sent via facsimile to those prospective Proposers who choose to be contacted via fax. A Purchase Order 13 City of Miami, Florida Group Health Benefits for Part time Employees RFP 03-04-004 will not be issued by the City unless the Successful Proposer has registered on-line. For any questions, contact the Vendor Registration Sec4ioh/at (305) 416-1913. 3.14._ Public Entity Crimes A person or affiliate who has been placed on the convicted Proposer list following a conviction for a public entity crime may not submit a proposal on a contract to provide any goods or services to a public entity, may not submit a Response on a contract with a public entity for the construction or repair of a public building or public work's project, may not submit a response on a lease of real property to a public entity, may not be awarded or perform work was a contractor, supplier, subcontractor, or consultant under a contract with any public entity, and may not transact business with any public entity in excess of the threshold amount provided in Section 287.017 of Florida Statutes for Category Two Tor a period of 36 months from the date of being placed on the convicted Bidder / Proposer list. 3.15. Resolution of Protests Any actual or prospective contractual party who feels aggrieved in connection with the solicitation or award of a contract may protest in writing to the Director of Purchasing/Chief Procurement Officer who shall have the authority, subject to the approval of the City Manager and the City Attorney, to settle and resolve a protest with final approval by the City Commission. Bidders are alerted to Section 18-103 of the City's Ordinance No. 12271 describing the protest procedures. Protests failing to meet the requirements for filing shall not be accepted. Failure of a party to timely file shall constitute a forfeiture of such parry's right to file a protest. NO EXCEPTIONS. 3.16. Review of Proposals for Responsiveness Each Proposal will be reviewed to determine if it is responsive to the submission requirements outlined in the RFP. A "responsive" Proposal is one which follows the requirements of the RFP, includes all documentation, is submitted in the format outlined in the RFP, is of timely submission, and has appropriate signatures as required on each document. Failure to comply with these requirements may deem a Proposal non -responsive. A responsible Proposer is one that has the capability in all respects to fully perform the requirements set forth in the Proposal, and that has the integrity and reliability, which will assume good faith performance. 3.17. Sales Tax The City is State Sales Tax exempt. Notwithstanding, Proposers should be aware of the fact that all materials and supplies which are purchased by the Proposer for the completion of the contract is subject to the Florida State Sales Tax in accordance with Section 212.08 Florida Statutes amended 1970 and all amendments thereto and shall be paid solely by the Proposer. 3.18. Subcontractors of Work Shall Be Identified With its Response, the Proposer should identify any and all Subcontractors, if applicable, and should they be known at the time, that will be used in the performance of the proposed Contract, their capabilities, experience, minority designation,- as defined in Ordinance 10062 and a brief description of the work to be performed by the subcontractor(s), if applicable. 14 City of Miami, Florida Group Health Benefits for Part time Employees RFP 03-04-004 The Successful Proposer shall not, at any time during the term of the Contract, subcontract any part of his operations or assign any portion or part;of the Contract to subcontractor(s) not mentioned in its Proposal without prior written consent of the City. Nothing contained in this RFP shall be consti.ied as establishing any contractual relationship between any subcontractor(s) and the City. The Successful Proposer shall be fully responsible to the City for the acts and omissions of the subcontractor(s) and their employees, as for acts and omissions of persons employed by Successful Proposer. 3.19. Employees are Responsibility of Successful Proposer All employees of the Successful Proposer shall be considered to be, at all times, employees of the Successful Proposer under its sole direction and not employees or agents of the City. The Successful Proposer shall supply competent and physically capable employees. The City may require the Successful Proposer to remove an employee the City deems careless, incompetent, insubordinate or otherwise objectionable and whose continued employment under this contract is not in the best interest of the City. Each employee shall have and wear proper identification. All the services required herein shall be performed by the Successful Proposer, and all personnel engaged in performing the services shall be fully qualified to perform such services. All personnel of the Successful Proposer shall be covered by Workmen's Compensation, unemployment compensation, and liability insurance, a copy of which is to be provided to the City. See the document entitled Insurance Requirements for specific requirements. All applicable taxes, fringe benefits, and training for all personnel for the performance under the contract shall be the sole responsibility of the Successful Proposer. 3.20. Use of Name The City is not engaged in research for advertising, sales promotion, or other publicity purposes. No advertising, sales promotion or other publicity materials containing information obtained from this Proposal are to be mentioned, or imply the name of the City, without prior express written permission of the City. 3.21. Collusion The Proposer, by submitting a Proposal, certifies that its Proposal is made without previous understanding, agreement or connection either with any person, firm, or corporation submitting a Proposal for the same services, or with the City's Purchasing Department or initiating Department. The Proposer certifies that its Proposal is fair, without control, collusion, fraud, or other illegal action. The Proposer further certifies that it is incompliance with the conflict of interest and code of ethics laws. The City will investigate all situations where collusion may have occurred and the City reserves the right to reject any and all Proposals where collusion may have occurred. 3.22. Compliance with Federal Standards All goods to be purchased under this RFP, if any, shall be in accordance with all governmental standards, which include, but are not be limited to, the standards issued by the Office of Safety and 15 City of Miami, Florida Group Health Benefits for Part time Employees RFP 03-04-OO4 a1 Health Administration (OSHA), the National Institute of Occupational Safety Hazards (NIOSH), and the National Fire Protection Association ( rF m. 3.23. Sales Tax The City is State Sales Tax exempt. Notwithstanding, Proposers should be aware of the fact that all materials and supplies which are purchased by the Proposer for the completion of the contract shall be subject to the Florida State Sales Tax in accordance with Section 212.08 Florida Statutes amended 1970 and all amendments thereto and, shall be paid solely by the Successful Proposer. 16 City of Miami, Florida Group Health Benefits for Part time Employees RFP 03-04-004 4.0. SPECIAL CONDITIONS 4.1. Authorization w, Upon authorization of the City Commission, the City Manager or his designee shall negotiate all aspects of the Contract with the Successful Proposer. The City Attorney's Office will provide assistance to the City Manager or his designee during the negotiation of the Contract and must approve the Contract as to legal form and correctness prior to the City Commission's authorization for the execution of the Contract by the City Manager. The Contract shall comply with all applicable laws, City Charter, and code provisions. 4.2. General Provisions of Contract with Successful Proposer The Contract shall address, but not be limited to, the following terms and conditions: 4.2.1. Amendments to the Contract The City Manager shall have sole authority to amend the Contract on behalf of the City. 4.2.2. Assignment Of Contract The Successful Proposer shall not assign any portions thereof, or any part of his/her operations, without written permission granted by the City through the City Manager, in the City's sole discretion. 4.2.3. Audit Rights and Records Retention The Successful Proposer agrees to provide access to the City, or any of its duly authorized representatives, to any books, documents, papers, and records of the contractor which are directly pertinent to this Agreement, for the purpose of audit, examination, excerpts, and transcriptions. The Successful Proposer shall maintain and retain any and all of the aforementioned records for three (3) years after the City makes final payment and all other pending matters are closed. On an ongoing basis, the most recent Financial Statements and audit reports, whether internal or outside audits, must be provided to the City. 4.2.4. Compliance with Orders And Laws The Successful Proposer shall comply with all local, state, and federal directives, ordinances, rules, orders, and laws as applicable to this RFP. Non-compliance with all local, state, and federal directives, orders, and laws may be considered grounds for termination of Contract. 4.2.5. Conflict Of Interest If any individual member of a proposing team, or an employee of a proposing team/firm, or an immediate family member of the same is also a member of any board, commission, or agency of the City, that individual is subject to the conflict of interest provisions of the City Code, Section 2-611. The Code states that no City officer, official, employee or board, commission or agency member, or a spouse, son, daughter, parent, brother or sister of such person, shall enter into any contract, transact any business with the City, or appear in representation of a third party before the City Commission. This prohibition may be waived in certain instances by the affirmative vote of 4/5 of 17 City of Miami, Florida Group Health Benefits for Part time Employees RFP 03-04-004 the City Commission, after a public hearing, but is otherwise strictly enforced and remains effective for two years subsequent to a person's departpre from City employment or board, commission or agency membership. ii This 1Srohibition does not preclude any person to whom it applies from submitting a Proposal. However, there is no guarantee or assurance that such person will be able to obtain the necessary waiver from the City, even if such person were the Successful Proposer. A Letter indicating a conflict of interest for each individual to whom it applies shall accompany the submission package. The letter must contain the name of the individual who has the conflict; the relative(s), office, type of employment or other situation which may create the conflict; the board on which the individual is or has served; and the dates of service. 4.2.6. Contract Administrator The City's Contract Administrator for the Contract shall be: Name Ramona Fiumara Assistant Director Department Risk Management Address 444 S.W. 2nd Avenue, 9th Floor Miami, Florida 33130 4.2.7. Contract / Project Manager Proposer shall include the name and telephone, and/or beeper number of the intended City's Account Representative. In the event the Contract is awarded to Proposer, the City's Project Manager designated by Proposer, shall be available at one of these contact numbers on a daily basis during at least regular business hours, Monday through Friday, for purposes of addressing complaints and receiving information as to Contract performance. Should the Project Manager deemed acceptable by the City leave the Successful Proposer's firm for any reason, the City reserves the right to accept or reject any other proposed Project Manager. 4.2.8. Indemnification The Successful Proposer shall agree to indemnify, defend and hold harmless the City and its officials, employees and agents (collectively referred to as "Indemnities") and each of them from and against all losses, costs, penalties, fines, damages, claims, expenses (including attorney's fees), liabilities (collectively referred to as "Liabilities") by reason of any injury to or death of any person or damage to or destruction or loss of any property arising out of, resulting from, or in connection with (i) the performance or non-performance of the services contemplated by the Contract which is or is alleged to be directly or indirectly caused, in whole or in part, by any act, omission, default or negligence (whether active or passive) of the Indemnities, or any of them or (ii) the failure of the Successful Proposer to comply with any of the requirements specified within the Contract, or the failure of the Successful Proposer to conform to statutes, ordinances, or other regulations or requirements of any governmental authority, federal or state, in connection with the performance under the Contract. Successful Proposer expressly agrees to indemnify and hold harmless the Indemnities, or any of them, from and against all liabilities which may be asserted by an employee I8 City of Miami, Florida Group Health Benefits for Part time Employees RFP 03-04-004 or former employee of Successful Proposer, or any of its subcontractors, if applicable and as provided above, for which the Successful Proirsec's liability to such employee or former employee would otherwise be limited tq,payments under state Workers' Compensation or similar laws. 4.9. Insurance Within ten (10) days after notification of award, the Successful Proposer shall furnish Evidence of Insurance to the Purchasing Department. Please refer to Section 6.2 Indemnification and Insurance. Execution of a Contract is contingent upon the receipt of proper insurance documents. If the insurance certificate is received within the specified time frame but not in the manner prescribed in this RFP, the Successful Proposer shall be verbally notified of such deficiency and shall have an additional five (5) calenda"r days to submit a corrected certificate to the City. If the Successful Proposer fails to submit the required insurance documents in the manner prescribed in this RFP, within fifteen (15) calendar days after the Successful Proposer has been made aware of Commission award, the Successful Proposer may be in default of the contractual terms and conditions. Under such circumstances, the Successful Proposer may be prohibited from submitting future proposals to the City. Information regarding any insurance requirements shall be directed to the Risk Management Administrator, Risk Management Department, at (305) 416-1700. Additionally, Successful Proposer may be liable to the City for the cost of re -procuring the services, caused by Successful Proposer's failure to submit the require documents. 4.2.10. Hold Harmless The Successful Proposer shall hold harmless and indemnify the City for any errors in the provision of services and for any fines which may result from the fault of the Successful Proposer. 4.2.11. Proposer's Warranty Proposer warrants that no one was paid a fee, commission, gift, or other consideration contingent upon receipt of an award for the services specified herein. 19 City of Miami, Florida Group Health Benefits for Part time Employees RFP 03-04-004 5.0. INSTRUCTIONS FOR SUBMITTING A PROPOSAL The following information and documents areJrequired to be provided with Proposer's Response to this RFP. Failure to do so mdy deem your proposal non -responsive. 5.1. Instructions to Proposers The purpose of this RFP is seeking Proposals from qualified and experienced sources to provide Group Health Benefits to Part-time City Employees, for the Department of Risk Management. Therefore, only fully capable, experienced, and qualified Proposers should submit Proposals in response to this RFP. Any firm(s) involved in a joint venture in its Proposal will be evaluated individually, as each firm of the joint venture would have to stand on its own merits. Proposer must clearly reflect in its Proposal any Sub -Contractors proposed to be utilized, and provide for the Sub -Contractor the same information required of Proposer. The City retains the right to accept or reject any Sub -Contractors proposed. Throughout this RFP, the phrases "must" and "shall" will denote mandatory requirements. Any Proposer's proposed system that does not meet the mandatory requirements is subject to immediate disqualification. When responding to this RFP, all Proposers shall adhere to the guidelines defined below. Any and all Proposals that do not follow the prescribed format are subject to immediate disqualification. 5.1.1. Submission Requirements PROPOSAL FORMAT The following documentation shall be included as a minimum in the Proposal and submitted to the City. Instructions to Proposers: Proposers should carefully follow the format and instructions outlined below, observing format requirements where indicated. Proposals must contain the information itemized below and in the order indicated. This information should be provided for the Proposer and any Sub -Contractors to be utilized for the work contemplated by this RFP. Proposals submitted which do not include the following items may be deemed non -responsive and may not be considered for contract award. The response to this solicitation should be presented in the following format. Failure to do so may deem your Proposal non -responsive. L Cover Page The Cover Page should include the Proposer's name; Contact Person for the RFP; Firm's Liaison for the Contract; Local Office Location; Local Business Address, if applicable; Business 20 City of Miami, Florida Group Health Benefits for Part time Employees RFP 03-04-004 Phone and Fax Numbers, if applicable Email addresses; Title of RFP; RFP Number; Federal Employer Identification Number or Social Sec t-itNumber. 2. Table of Contents The table of contents should outline, in sequential order, the major sections of the proposal as listed below, including all other relevant documents requested for submission. All pages of the proposal, including the enclosures, should be clearly and consecutively numbered and correspond to the table of contents. . 3. Executive Summary: A signed and dated summary of not more than two (2) pages containing Overall Qualifications and Experience; Proposer's Ability and Capability to Provide Required Services; and Proposed Plan(s), Network, and Employee Cost(s), as contained in the submittal. Include the name of the organization, business phone and contact person. 4. Overall Qualifications and Experience a) Describe the Proposer's organizational history and structure; years Proposer and/or firm has been in business providing a similar service(s), and indicate whether the City has previously awarded any contracts to the Proposer/firm. b) Provide a list of principals, owners or directors. c) Provide a verification letter from State of Florida, Department of Insurance, reflecting Proposer is currently and properly authorized to conduct business in the State of Florida_ d) Provide current NCQA Accreditation Letter for commercial/HMO/POS combined business, and AM Best certificate, and State of Florida Department of Insurance letter, stating you are meeting current Reserve Factors. e) Demonstrate your qualifications and other relevant experience in areas similar to the Scope of Work, magnitude, and complexity identified within this RFP. f) Provide a complete list of clients for which Proposer has provided a similar service(s) as required in this RFP, particularly those of governmental entities, for whom similar services have been performed during the past five (5) years. Include the name, address, name of contact, and telephone number of each reference. The City reserves the right to contact any reference as part of the evaluation process. g) Provide a complete list of the personnel, including the Project Manager and any sub -consultants, that will be assigned to handle the work to be performed for the City. Include a resunie describing their experience, training, certifications, and other relevant details. Personnel should additionally be identified by race/ethnicity, and gender. h) Provide one (1) Letter of Reference on letterhead from entities, particularly from a governmental entity of a similar size for whom similar services have been performed. 21 Ciry of Miami, Florida Group Health Benefits for Part time Employees RFP 03-04-004 5. Proposed Plau(s), Network, and Employee Cost(s) a) Detail its overall Plan and ijs approach to provide a Health Benefit Plan for the City's partlime employees. b) Provide description of Levels of coverage and applicable premiums prescription benefits, and co -pays for each Level of Service proposed. c) Detail its Network, including hospitals, physicians, specialists, etc. in Miami - Dade, Broward, and Palm Beach Counties. d) Provide monthly cost, per part time City employee, for each proposed Level of Service. 6. Proposer's Ability and Capability to Provide Required Services a) Describe the overall size of Proposer and include a description of how the Proposer intends to staff this engagement. List the office from where the work for the City is to be performed, and discuss any as additional needs that might be requested of the City pursuant to the Scope of Work. b) Provide copy of the most current audited Financial Statement, or current unaudited Financial Statement, during the past year. c) Provide information as to any and all pending or previous lawsuits, including the disposition of same, filed against the Proposer relating to similar services being sought within this RFP. 7. Minority/Women Participation, if applicable For the purposes of this RFP, a certified M/WBE is one which has been certified by the City or the State of Florida as a Black, Female, or Hispanic business enterprise. Entities which are MIWBE certified by the Miami -Dade County Public Schools or Miami -Dade County must be certified prior to Proposal submission, and must be certified as an M/WBE by the City prior to evaluation of Proposal by the Evaluation Committee. • For Proposers seeking M/WBE consideration in the evaluation process, the following documents must be submitted with Proposal, if applicable: • City, Miami -Dade County Public Schools, Miami -Dade County, or the State of Florida MIWBE Certificate/letter evidencing current certification status • City Minority/Business Affairs Registration Affidavit • For Proposers seeking EEO consideration in the evaluation process, Proposers must provide the names of key personnel by race, gender and ethnicity. 8. Local Preference • For Proposers seeking 'Deal preference consideration in the evaluation process, the following information must be provided with proposal. • State the Office Location of the Proposer, and complete Affidavit. (Refer to Section 3.7 Local Preference) • Provide location from which the Proposer will be based to perform the work. 22 City of Miami, Florida Group Health Benefits far Part time Employees RFP 03-04-004 9. Trade Secrets Execution to Public Records Disclosure All Proposals submitted to the City are subjecy to public disclosure pursuant to Chapter 119, Florida Statutes. An exception may be made for "trade secrets." If the Proposal contains information that constitutes a "trade secret", all material that qualifies for exemption from Chapter 119 must be submitted in a separate envelope, clearly identified as "TRADE SECRETS EXCEPTION," with your firm's name and the RFP number marked on the outside. Please be aware that the designation of an item as a trade secret by you may be challenged in court by any person. By your designation of material in your Proposal as a "trade secret" you agree to indemnify and hold harmless the City for any award to a plaintiff for damages, costs or attorney's fees and for costs and attorney's fees incurred by the City by reason of any legal action challenging your claim. 10. Affidavits / Acknowledgments • Proposers should complete and submit as part of its Proposal all of the following forms and/or documents: • 6.1 RFP Information Form • 6.2 Certificate of Authority • 6.3 Insurance Requirements • 6.4 Local Office Affidavit • 6.5 Debarment and Suspension Certificate • 6.6 Statement of Compliance with Ordinance 10032 • 6.7 Copy of Proposer's Occupational License • 6.8 Proof of current Miami M/WBE Certification, if applicable • 6.9 Conflict of Interest, if applicable • 6.10 Complete Proposal, including all required documentation. • 6.11 Completed Attachments regarding required and optional services 5.2. Response Format Ten (10) bound copies of your complete response to this RFP must be delivered to: Ms. Priscilla A. Thompson, City Clerk City of Miami Office of the City Clerk First Floor 3500 Pan American Drive Miami, Florida 33133 Responses must be clearly marked on the outside of the package referencing RFP NO. 03-04- 004, Group Health Benefits for Part-time Employees. Responses received after that date and time will not be accepted and shall be returned unopened to Proposer. 23 City of Miami, Florida Group Health Benefits for Part time Employees REP 03-04-004 Proposals received at any other location than the aforementioned or after the Proposal submission date and time shall be deemed noyiuspansive. Proposals should be signed byin official authorized to bind the Proposer to the provisions given in the Proposal. Proposals are to remain valid for at least 180 days. Upon award of a Contract, the contents of the Proposal of the Successful Proposer may be included as part of the Contract, at the City's discretion. 5.3 EVALUATION CRITERIA Proposals shall be evaluated based upon the following criteria and weight. CRITERIA PERCENTAGE Overall Qualifications and Experience 25 Proposed Plan(s), Network, and Employee Cost(s) 50 Proposer's Ability and Capability to Provide Required Services 15 Minority / Women Participation, if applicable 5 Local Preference, if applicable 5 100% 24 City of Miami, Florida Group Health Benefits for Part time Employees RFP 03-04-004 Sec. 18-105. First -source hiring agreements. (a) The commission approves implementation of the first -source hiring agreement policy and requires as a condition precedenfto the execution of service contracts for facilities, services, and/or receipt of grants and loans, for projects of a nature that create new jobs, the successful negotiation of first -source hiring agreements between the organization or individual receiving said contract and the authorized representative unless such an agreement is found infeasible by the city manager and such finding approved by the city commission at a public hearing. (b) For the purpose of this section, the following terms, phrases, words and their derivations shall have the following meanings: Authorized representative means the Private Industry Council of South Florida/South Florida Employment and Training Consortium, or its successor as local recipient of federal and state training and employment funds. Facilities means all publicly financed projects, including but without limitation, unified development projects, municipal public works, and municipal improvements to the extent they are financed through public money services or the use of publicly owned property. Grants and loans means, without limitation, urban development action grants (UDAG), economic development agency construction loans, loans from Miami Capital Development, Incorporated, and all federal and state grants administered by the,city. Service contracts means contracts for the procurement of services by the city which include professional services. 25 City of Miami, Florida Group Health Benefits for Part time Employees RFP 03-04-004 Services includes, without limitation, public works improvements, facilities, professional services, commodities, supplies, materials and equipment,, 4 f 110 (c) The authorized representative shall negotiate each first -source hiring agreement. (d) The primary beneficiaries of the first -source hiring agreement shall be participants of the city training and employment programs, and other residents of the city. (Ord. No. 10032, §§ 1--4, 9-12-85; Code 1980, § 18-11) 26 City of Miami, Florida Group Health Benefits for Part time Employees RFP 03-04-004 6.0. RFP Response Forms - CHECK LIST # This checklist is provided to hey you conform with all form/document requirements stipulated in this RFP. Submitted With Proposal 6.1 RFP Information Form This form must be completed, sued, and returned with Proposal. YES 6.2 Certificate of Authority, to be completed, signed and returned with Proposal. YES 6.3 Insurance Requirements, Acknowledgment of receipt of information on the insurance requirements for this YES RFP. (Must be signed). 6.4 Local Office Affidavit, if applicable YES 6.5 Debarment and Suspension Certificate (must be signed) YES 6.6 Statement of Compliance with Ordinance 10032 YES 6.7 Proof of current M/WRE Certification by City, if applicable YES 6.8 Conflict of Interest, if applicable YES 6.9 Complete Proposal with all required documentation. YES 27 City of Miami, Florida Group Health Benefits for Part time Employees RFP 03-04-004 6.1. RFP Information Form Mailing Date: November 14,12003 RFP No.: = 03-04-004 Buyer: Pamela Burns, CPPB Email: pburns(a,ci.miami.tl.us Commodity Codes: 918-69; 948-42; 953-48; 953-63; 962-47 TERM CONTRACT for Group Health Benefits for Part-time City Employees RFP NO. 03-04-004 I certify that any and all information contained in this Proposal is true; and I further certify that this Proposal is made without prior understanding, agreement, or connections with any corporation, firm or person submitting a Proposal for the same materials, supplies, equipment, or services and is in all respects fair and without collusion or fraud. I agree to abide by all terms and conditions of the RFP, and certify that I am authorized to sign for the Proposer. Please print the following and sign your name: Firm's Name: Telephone: Principal Business Address: Fax: E-mail address: Name: Mailing Address: Title: Authorized Signature: 28 City of Miami, Florida Group Health Benefits for Part time Employees RFP 03-04-004 go STATE OF COUNTY OF W3 ) SS: ) CERTIFICATE OF AUTHORITY (IF CORPORATION) I HEREBY CERTIFY that a meeting of the Board of Directors of the a corporation existing under the laws of the State of , held on , 20 the following resolution was duly passed and adopted: "RESOLVED, that, as President of the Corporation, be and is hereby authorized to execute the Proposal dated, , 20 , to the City of Miami and this corporation and that their execution thereof, attested by the Secretary of the Corporation, and with the Corporate Seal affixed, shall be the official act and deed of this Corporation." I further certify that said resolution is now in full force and effect. IN WITNESS WHEREOF, I have hereunto set my hand and affixed the official seal of the corporation this day of , 20 Secretary: (SEAL) FAILURE TO COMPLETE, SIGN, AND RETURN THIS FORM MAY DISQUALIFY YOUR RESPONSE. 29 aI STATE OF ) SS: COUNTY OF 4l CERTIFICATE OF AUTHORITY (IF PARTNERSHIP) 1 HEREBY CERTIFY that a meeting of the Partners of the organized and existing under the laws of the State of , held on , 20 , the following resolution was duly passed and adopted: "RESOLVED, that, , as of the Partnership, be and is hereby authorized to execute the Proposal dated, 20 , to the City of Miami and this partnership and that their execution thereof, attested by the shall be the official act and deed of this Partnership." I further certify that said resolution is now in full force and effect. IN WITNESS WHEREOF, I have hereunto set my hand this , day of 20 Secretary: (SEAL) FAILURE TO COMPLETE, SIGN, AND RETURN THIS FORM MAY DISQUALIFY YOUR RESPONSE. CERTIFICAIEJIQF AUTHORITY (IF JOINT VENTURE) STATE OF ) SS: COUNTY OF I HEREBY CERTIFY that a meeting of the Principals of the organized and existing under the laws of the State of , 20 , the following resolution "RESOLVED, that, as be and is hereby authorized to execute the Proposal dated, official act and deed of this Joint Venture." I further certify that said resolution is now in full force and effect. , held on was duly passed and adopted: of the Joint Venture IN WITNESS WHEREOF, I have hereunto set my hand this , day of , 20 Secretary: (SEAL) 20 , to the City of Miami FAILURE TO COMPLETE, SIGN,_ AND RETURN THIS FORM MAY DISQUALIFY YOUR RESPONSE. City of Miami, Florida Group Health Benefits for Part time Employees RFP 03-04-004 CERTIFICATE OF AUTHORITY (if individual) STATE OF ) ) SS: COUNTY OF ) I HEREBY CERTIFY that as an individual, I (Name of Individual) and as a d/b/a (doing business as) (if applicable) exist under the laws of the State of Florida. "RESOLVED, that, as an individual and/or d/b/a (if applicable), be and is hereby authorized to execute the Proposal dated, , 20 , to the City of Miami as an individual and/or d/b/a (if applicable) and that my execution thereof, attested by a Notary Public of the State, shall be the official act and deed of this attestation." I further certify that said resolution is now in full force and effect. IN WITNESS WHEREOF, I have hereunto set my hand and affixed the official seal of Notary Public this , day of , 20 NOTARY PUBLIC: Commission No.: I personally know the individual/do not know the individual (Please Circle) Driver's License # (SEAL) FAILURE TO COMPLETE, SIGN, AND RETURN THIS FORM MAY DISQUALIFY YOUR RESPONSE 6.2. Indemnification and Insurance wy INDEMNIFICATION Proposer shall indemnify, defend and hold harmless the City and its officials, employees and agents (collectively referred to as "Indemnities") and each of them from and against all loss, cost, penalties, fmes, damages, claims, expenses (including attorney's fees) or liabilities (collectively referred to as "Liabilities") by reason of any injury to or death of any person or damage to or destruction or loss of any property arising out of, resulting from, or in connection with (i) the performance or non-performance of the services contemplated'by the Contract which is or is alleged to be directly or indirectly caused, in whole or in part, by any act, omission, default or negligence (whether active or passive) of proposer or its employees, agents, or subcontractors (collectively referred to as "proposer"), regardless of whether it is, or is alleged to be, caused in whole or part (whether joint, concurrent, or contributing) by any act, omission, default or negligence (whether active or passive) of the Indemnities, or any of them or (ii) the failure of the proposer to comply with any of the provisions in the Contract or the failure of the proposer to conform to statutes, ordinances or other regulations or requirements of any governmental authority, federal or state, in connection with the performance of the Contract. Proposer expressly agrees to indemnify and hold harmless the Indemnities, or any of them, from and against all liabilities which may be asserted by an employee or former employee of proposer, or any of its subcontractors, as provided above, for which the proposer's liability to such employee or former employee world otherwise be limited to payments under state Workers' Compensation or similar laws. Proposer further agrees to indemnify, defend and hold harmless the Indemnities from and against (i) any and all Liabilities imposed on account of the violation of any law, ordinance, order, rule, regulation, condition, or requirement, in any way related, directly or indirectly, to proposer's performance under the Contract, compliance with which is left by the Contract to the proposer, and (ii) any and all claims, and/or suits for labor and materials furnished by the proposer or utilized in the performance of the Contract or. otherwise. Where not specifically prohibited by law, proposer further specifically agrees to indemnify, defend and hold harmless the Indemnities from all claims and suits for any liability, including, but not limited to, injury, death, or damage to any person or property whatsoever, caused by, arising from, incident to, connected with or growing out of the performance or non-performance of the Contract which is, or is alleged to be, caused in part (whether joint, concurrent or contributing) or in whole by any act, omission, default, or negligence (whether active or passive) of the Indemnities. The foregoing indemnity shall also include liability imposed by any doctrine of strict liability. The proposer shall furnish to City of Miami, c/o Depa,tulent of Purchasing, 444 SW 2" Avenue, 6th Floor, Miami, Florida 33130, Certificate(s) of Insurance prior to contract execution which indicate that insurance coverage has been obtained which meets the requirements as outlined below: A. Workers' Compensation Insurance for all employees of the proposer as required by Florida Statute 440. B. Public Liability Insurance on a comprehensive basis in an amount not Tess than $1.000,000.00 combined single limit per occurrence for bodily injury and property damage. City must be shown as an additional insured with respect to this coverage. C. Automobile Liability Insurance covering all owned, non -owned and hired vehicles used in connection with the work in an amount not less than statutory combined single limit per occurrence for bodily injury and property damage. D. Professional Liability Insurance with Minimum Limits of$1,000,000.00 per occurrence. The City is required to be named as additional insured. BINDERS ARE UNACCEPTABLE. The insurance coverage required shall include those classifications, as listed in standard liability insurance manuals, which most nearly reflect the operations of the Proposer. City of Miami, Florida Group Health Benefits for Part-time / Temporary Employees RFP 03-04-004 Indemnification and Insurance (cont.) All insurance policies required a'6bve shall be issued by companies authorized to do business under the laws of the State,of Florida, with the following qualifications: The Company must be rated no less than "A" as to management, and no fess than "Class X" as to financial strength, by the latest edition of Best's Key Rating Insurance Guide or acceptance of insurance company which holds a valid Florida Certificate of Authority issued by the State of Florida, Department of Insurance, and are members of the Florida Guarantee Fund. Certificates will indicate no modification or change in insurance shall be made without thirty (30) days written advance notice to the certificate holder. NOTE: CITY RFP NUMBER AND/OR TITLE OF RFP MUST APPEAR ON EACH CERTIFICATE. Compliance with the foregoing requirements shall not relieve the proposer of his liability and obligation underthis section or under any other section of this Agreement. The proposer shall be responsible for assuring that the insurance certificates required in conjunction with this Section remain in force for the duration of the contractual period; including any and all option terms that may be granted to the Successful Proposer. —If insurance certificates are scheduled to expire during the contractual period, the proposer shall be responsible for submitting new or renewed insurance certificates to the City at a minimum of ten (I0) calendar days in advance of such expiration. --In the event that expired certificates are not replaced with new or renewed certificates which cover the contractual period, the City shall; A) Suspend the Contract until such time as the new or renewed certificates are received by the City in the manner prescribed in the RFP. B) The City may, at its sole discretion, terminate the Contract for cause and seek re -procurement damages from the proposer in conjunction with the violation of the terms and conditions of the Contract. The undersigned proposer acknowledges that (s)he has read the above information and agrees to comply with all the above City requirements. Proposer: Date: (Company name) Signature: Print Name: FAILURE TO COMPLETE, SIGN, AND RETURN THIS FORM MAY DISQUALIFY YOUR RESPONSE. 41 City of Miami, Florida Group Health Benefits for Part-time / Temporary Employees RFP 03-04-004 6.3. Local Office Affidavit Please type or print clearly. This Affidavit must be completed in full, signed and notarized ONLY if your office is located within the eorpoynte limits of the City of Miami. Legal Name of Firm: Entity Type: (check one box only) [] Partnership [) Sole Proprietorship [] Corporation Corporation Doc. No: Date Established: Occupational License No: Date of Issuance: PRESENT Street Address: City: State: How long at this location: PREVIOUS Street Address: City: State How long at this Location: According to Ordinance No. 12271 (Section 18-85): The City Commission may offer to a responsible and responsive local bidder, who maintains a Local Office, the opportunity of accepting a bid at the low bid amount, if the original bid amount submitted by the local vendor is not more than ten percent (10%) in excess of the lowest other responsible and responsive bidder. The intention of this section is to benefit local bona fide bidders/proposers to promote economic development within the corporate limits of the City of Miami. I (we) certify, under penalty of perjury, that the office location of our firm has not been established with the sole purpose of obtaining the advantage granted bona fide local bidders/proposers by this section. Authorize Signature Print Name (('ol'pora'iSeal) Title Authorize Signature Print Name Title (Must be signed by the corporate secretary of a Corporation or one general partner of a partnership or the proprietor of a sole proprietorship or all partners of ajoint venture.) STATE OF FLORIDA, COUNTY OF MIAMI-DADE [] Personally known to me; or Subscribed and Sworn before me that this is a true statement this day of 200 . [] Produced identification: Notary Public, State of Florida My Commission expires Printed name of Notary Public Please submit with your bid copies of Occupational License, professional and/or trade License to verify local status. The City of Miami also reserves the right to request a copy of the corporate charter, corporate income tax filing return and any other documents(s) to verify the location of the firm's office location. 42 City of Miami, Florida Group Health Benefits for Part-time / Temporary Employees RFP 03-04-004 6.4. Debarment And Suspension j CITY OF ML4MfI CODE SEC. 18-56.4 (a) Authority and requirement to debar and suspend: After reasonable notice to an actual or prospective contractual party, and after reasonable opportunity to such party to be heard, the City Manager, after consultation with the Chief Procurement Officer and the City Attorney, shall have the authority to debar a contractual party for the causes Iisted below from consideration for award of city contracts. The debarment shall be for a period of not fewer than three (3) years. The City Manager shall also have the authority to suspend a contractor from consideration for award of city contracts if there is probable cause for debarment. Pending the debarment determination, the authority to debar and suspend contractors shall be exercised in accordance with regulations which shall be issued by the Chief Procurement Officer after approval by the City Manager, the City Attorney, and the City Commission. (b) Causes for debarment or suspension include the following: 1. Conviction for commission of a criminal offense incident to obtaining or attempting to obtain a public or private contract or subcontract, or incident to the performance of such contract or subcontract; 2. Conviction under state or federal statutes of embezzlement, theft, forgery, bribery, falsification or destruction of records, receiving stolen property, or any other offense indicating a lack of business integrity or business honesty; 3. Conviction under state or federal antitrust statutes arising out of the submission of bids or proposals; 4. Violation of contract provisions, which is regarded by the Chief Procurement Officer to be indicative of non -responsibility. Such violation may include failure without good cause to perform in accordance with the terms and conditions of a contract or to perform within the time limits provided in a contract, provided that failure to perform caused by acts beyond the control of a party shall not be considered a basis for debarment or suspension; 5. Debarment or suspension of the contractual party by any federal, state or other governmental entity; 6. False certification pursuant to paragraph (c) below; or 7. Any other cause judged by the City Manager to be so serious and compelling as to affect the responsibility of the contractual party performing city contracts. (e) Certification: All contracts for goods and services, sales, and leases by the City shall contain a certification that neither the contractual party nor any of its principal owners or personnel have been convicted of any of the violations set forth above or debarred or suspended as set forth in paragraph (b) (5). The undersigned hereby certifies that neither the contractual party nor any of its principal owners or personnel have been convicted of any of the violations set forth above, or debarred or suspended as set forth in paragraph (b) (5). Company name: Signature: Date: FAILURE TO COMPLETE, SIGN, AND RETURN THIS FORM MAY DISQUALIFY YOUR RESPONSE 43 City of'Miami, Florida Group Health Benefits for Part-time / Temporary Employees RFP 03-04-004 6.5. STATEMENT OF COMPLIA'(!'E WITH ORDINANCE NO. 10032 Proposer certifies that (s)he has wad and understood the provisions of City of Miami Ordinance No. 10032 (Section 18-105 of the City Code) pertaining to the implementation of a "First Source Hiring Agreement." Proposer will complete and submit the following questions as part of the RFP Proposal. Violations of this Ordinance may be considered cause for annulment of a Contract between the Proposer and the City of Miami. A. Do you expect to create new positions in your company in the event your company was awarded a Contract by the City? —Yes No B. In the event your answer to Question "A" is yes, how many new positions would you create to perform this work? C. Please list below the title, rate of pay, summary of duties, number of positions, and expected length or duration of all new positions which might be created as a result of this award of a Contract. 1) 2) 3) 4) 5) 6) 7) 8) (Use additional sheets if necessary) PROPOSER NAME: SIGNATURE/TITLE: DATE: FAILURE TO COMPLETE, SIGN, AND RETURN THIS FORM MAY DISQUALIFY YOUR RESPONSE. 44 City of Miami, Florida Group Health Benefits for Pan -time / Temporary Employees RFP 03-04-004 LIST OF,VXHIBITS Census data for: Exhibit A: Part-time/temporary employees working 70 hrs or less. (Approximately 295 employees working with the City as of the issuance of the RFP) Exhibit B: Part-time/temporary employees working 71 hours plus. (Approximately 205 employees working with the City as of the issuance of the RFP) Exhibit Cr Part-time/temporary employees working 70 hours or less for more than 90 days. (Approximately 291 employees on payroll with the City for more than 90 days) Exhibit D: Part-time/temporary employees working 71 hours plus for more than 90 days. (Approximately 196 employees on payroll with the City for more than 90 days) Exhibit E: Part-time/temporary employees working 70 hours or less for more than 90 days. (Approximately 291 employees on payroll with the City for more than 90 days) Exhibit F: Part-time/temporary employees working 71 hours plus for more than 1 year. (Approximately 141 employees on payroll with the City for more than 1 year) 45