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8339 - Amendment 1 Executed Docusign Transmittal Coversheet File Name Purchasing Contact Contract Expiration DocuSign Envelope ID: 4EF4BE60-5C55-44D7-8085-51A26A2EEAC0 Ginny Brummett NOVEMBER 14, 2028 8339 Stop Loss-Amendment 1 UHIC AMEND (07/06)1 UnitedHealthcare Insurance Company A Stock Company 185 Asylum Street Hartford, CT 06103-0450 AMENDMENT NO. 10 Amendment to be attached to and made a part of Group Policy No. GA-715130AL, issued by UnitedHealthcare Insurance Company (herein called "Company") to City of Denton (herein called "Policyholder"). It is agreed by and between the Company and the Policyholder that 1. The page entitled "Schedule Of Benefits" as contained in the Policy is hereby replaced with the attached page entitled "Schedule Of Benefits". 2. This Amendment will hereby be effective as of January 1, 2024. UnitedHealthcare Insurance Company UnitedHealthcare Insurance Company Jessica Paik, President UnitedHealthcare Insurance Company Tracy A. Arney, Secretary ACCEPTED BY: ______________________________________ Title:______________________________________ Date:______________________________________ DocuSign Envelope ID: 4EF4BE60-5C55-44D7-8085-51A26A2EEAC0 Buyer 2/15/2024 Total Rewards Manager 2/16/2024 UHILEIP-TX(07/06)2 SCHED UnitedHealthcare Insurance Company A Stock Company 185 Asylum Street Hartford CT 06103-0450 877-294-1429 SCHEDULE OF BENEFITS This Schedule of Benefits is only applicable to Excess Loss Insurance provided by the Company during the Policy Period shown below. Policyholder:City of Denton Policy Number:GA-715130 AL Effective Date:January 1, 2024 Subsequent Policy Period Effective Date:January 1, 2025 Administrator:UnitedHealthcare Services, Inc. Coverage specified herein is applicable only during the Policy Period from January 1, 2024 through December 31, 2024, and is further subject to all terms and conditions of this Policy. SPECIFIC EXCESS LOSS INSURANCE Benefit Period: Covered Expenses Incurred from January 1, 2013 through December 31, 2024 and Paid from January 1, 2024 through December 31, 2024. Specific Deductible per Covered Person: $185,000 Specific Percentage Reimbursable: 100% Maximum Specific Benefit per Covered Person: Unlimited per lifetime Specific Excess Loss Insurance includes: •Medical •Stand Alone Prescription Drug Program Specific Excess Loss Premium: $202.58 per subscriber per month AGGREGATE EXCESS LOSS INSURANCE Benefit Period: Covered Expenses Incurred from January 1, 2014 through December 31, 2024 and Paid from January 1, 2024 through December 31, 2024. Aggregate Excess Loss Insurance includes: •Medical •Stand Alone Prescription Drug Program Aggregate Percentage Reimbursable: 100% Maximum Aggregate Benefit: $1,000,000 per policy year Minimum Annual Aggregate Deductible: $34,615,081 or 95% of the first Monthly Aggregate Deductible amount times 12, whichever is greater. DocuSign Envelope ID: 4EF4BE60-5C55-44D7-8085-51A26A2EEAC0 UHILEIP-TX(07/06)3 SCHED Maximum Covered Expenses per Covered Person accumulating toward the Maximum Aggregate Benefit: $185,000 Monthly Aggregate Factors: $1904.90 per subscriber Aggregate Excess Loss Premium: $5.48 per subscriber per month The premium amount reflected above includes the following: •Aggregate Accommodation Endorsement DocuSign Envelope ID: 4EF4BE60-5C55-44D7-8085-51A26A2EEAC0 UHILEIP-TX(07/06)4 SCHED DocuSign Envelope ID: 4EF4BE60-5C55-44D7-8085-51A26A2EEAC0 Certificate Of Completion Envelope Id: 4EF4BE605C5544D7808551A26A2EEAC0 Status: Completed Subject: ***Purchasing Approval*** 8339 Stop Loss-Amendment 1 Source Envelope: Document Pages: 5 Signatures: 2 Envelope Originator: Certificate Pages: 5 Initials: 0 Ginny Brummett AutoNav: Enabled EnvelopeId Stamping: Enabled Time Zone: (UTC-06:00) Central Time (US & Canada) 901B Texas Street Denton, TX 76209 Ginny.Brummett@cityofdenton.com IP Address: 198.49.140.10 Record Tracking Status: Original 2/15/2024 3:32:01 PM Holder: Ginny Brummett Ginny.Brummett@cityofdenton.com Location: DocuSign Signer Events Signature Timestamp Ginny Brummett ginny.brummett@cityofdenton.com Buyer City of Denton Security Level: Email, Account Authentication (None) Signature Adoption: Pre-selected Style Using IP Address: 198.49.140.10 Sent: 2/15/2024 3:39:28 PM Viewed: 2/15/2024 3:39:37 PM Signed: 2/15/2024 3:39:50 PM Electronic Record and Signature Disclosure: Not Offered via DocuSign Cindy Hampton Cindy.Hampton@cityofdenton.com Total Rewards Manager Security Level: Email, Account Authentication (None)Signature Adoption: Pre-selected Style Using IP Address: 198.49.140.10 Sent: 2/15/2024 3:39:51 PM Viewed: 2/16/2024 7:04:21 AM Signed: 2/16/2024 7:04:46 AM Electronic Record and Signature Disclosure: Accepted: 2/16/2024 7:04:21 AM ID: 1243a629-8b8e-4ebc-9938-04ad121a69d4 In Person Signer Events Signature Timestamp Editor Delivery Events Status Timestamp Agent Delivery Events Status Timestamp Intermediary Delivery Events Status Timestamp Certified Delivery Events Status Timestamp Carbon Copy Events Status Timestamp Ginny Brummett ginny.brummett@cityofdenton.com Buyer City of Denton Security Level: Email, Account Authentication (None) Sent: 2/16/2024 7:04:48 AM Electronic Record and Signature Disclosure: Not Offered via DocuSign Carbon Copy Events Status Timestamp Cheyenne Defee cheyenne.defee@cityofdenton.com Procurement Administration Supervisor City of Denton Security Level: Email, Account Authentication (None) Sent: 2/16/2024 7:04:48 AM Electronic Record and Signature Disclosure: Not Offered via DocuSign Sandy Brown sbrown@McGriff.com Security Level: Email, Account Authentication (None) Sent: 2/16/2024 7:04:48 AM Electronic Record and Signature Disclosure: Not Offered via DocuSign Witness Events Signature Timestamp Notary Events Signature Timestamp Envelope Summary Events Status Timestamps Envelope Sent Hashed/Encrypted 2/15/2024 3:39:28 PM Envelope Updated Security Checked 2/15/2024 3:40:45 PM Certified Delivered Security Checked 2/16/2024 7:04:21 AM Signing Complete Security Checked 2/16/2024 7:04:46 AM Completed Security Checked 2/16/2024 7:04:49 AM Payment Events Status Timestamps Electronic Record and Signature Disclosure ELECTRONIC RECORD AND SIGNATURE DISCLOSURE From time to time, City of Denton (we, us or Company) may be required by law to provide to you certain written notices or disclosures. 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