8339 - Amendment 2 Executed
DocuSign Transmittal Coversheet
File Name
Purchasing Contact
Docusign Envelope ID: CCFFA286-8232-47A3-AD15-2BC10E17A216
8339 Stop Loss Insurance - Price Increase Amendment 2
Christina Dormady
UHIC AMEND (07/06) 1
UnitedHealthcare Insurance Company
A Stock Company
185 Asylum Street Hartford, CT 06103-0450
AMENDMENT NO. 11
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, 2025.
UnitedHealthcare Insurance Company
UnitedHealthcare Insurance Company
Jessica Paik, President
UnitedHealthcare Insurance Company
Tracy A. Arney, Secretary
ACCEPTED
BY:
______________________________________
Title: ______________________________________
Date: ______________________________________
Docusign Envelope ID: CCFFA286-8232-47A3-AD15-2BC10E17A216
11/15/2024
Total Rewards ManagerBuyer
11/15/2024
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
Original Effective Date: January 1, 2014
Subsequent Policy Period Effective
Date: January 1, 2026
Administrator: UnitedHealthcare Services, Inc.
Coverage specified herein is applicable only during the Policy Period from January 1, 2025 through December 31,
2025, 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, 2025 and Paid from
January 1, 2025 through December 31, 2025.
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: $212.71 per subscriber per month
AGGREGATE EXCESS LOSS INSURANCE
Benefit Period: Covered Expenses Incurred from January 1, 2014 through December 31, 2025 and Paid from
January 1, 2025 through December 31, 2025.
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: $36,922,020 or 95% of the first Monthly Aggregate Deductible amount
times 12, whichever is greater
Docusign Envelope ID: CCFFA286-8232-47A3-AD15-2BC10E17A216
UHILEIP-TX(07/06) 3 SCHED
Maximum Covered Expenses per Covered Person accumulating toward the Maximum Aggregate Benefit:
$185,000
Monthly Aggregate Factors: $1896.24 per subscriber
Aggregate Excess Loss Premium: $5.46 per subscriber per month
The premium amount reflected above includes the following:
• Aggregate Accommodation Endorsement
Docusign Envelope ID: CCFFA286-8232-47A3-AD15-2BC10E17A216
UHILEIP-TX(07/06) 4 SCHED
Docusign Envelope ID: CCFFA286-8232-47A3-AD15-2BC10E17A216
Certificate Of Completion
Envelope Id: CCFFA286823247A3AD152BC10E17A216 Status: Completed
Subject: ***Purchasing Approval*** 8338 - Stop Loss Insurance - Price Increase - Amendment 2
Source Envelope:
Document Pages: 5 Signatures: 2 Envelope Originator:
Certificate Pages: 2 Initials: 1 Christina Dormady
AutoNav: Enabled
EnvelopeId Stamping: Enabled
Time Zone: (UTC-06:00) Central Time (US & Canada)
901B Texas Street
Denton, TX 76209
christina.dormady@cityofdenton.com
IP Address: 198.49.140.10
Record Tracking
Status: Original
11/14/2024 3:45:58 PM
Holder: Christina Dormady
christina.dormady@cityofdenton.com
Location: DocuSign
Signer Events Signature Timestamp
Christina Dormady
christina.dormady@cityofdenton.com
Buyer
City of Denton
Security Level: Email, Account Authentication
(None)
Completed
Using IP Address: 198.49.140.10
Sent: 11/14/2024 3:49:40 PM
Viewed: 11/14/2024 3:49:48 PM
Signed: 11/14/2024 3:50:19 PM
Electronic Record and Signature Disclosure:
Not Offered via DocuSign
Lori Hewell
lori.hewell@cityofdenton.com
Purchasing Manager
City of Denton
Security Level: Email, Account Authentication
(None)
Signature Adoption: Pre-selected Style
Using IP Address: 198.49.140.10
Sent: 11/14/2024 3:50:20 PM
Viewed: 11/14/2024 3:58:24 PM
Signed: 11/15/2024 8:47:53 AM
Electronic Record and Signature Disclosure:
Not Offered via DocuSign
Misty Hambright
misty.hambright@cityofdenton.com
Total Rewards Manager
City of Denton
Security Level: Email, Account Authentication
(None)
Signature Adoption: Pre-selected Style
Using IP Address: 198.49.140.104
Sent: 11/15/2024 8:47:55 AM
Viewed: 11/15/2024 8:49:14 AM
Signed: 11/15/2024 8:49:43 AM
Electronic Record and Signature Disclosure:
Not Offered via DocuSign
Christina Dormady
christina.dormady@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: 11/15/2024 8:49:44 AM
Viewed: 11/15/2024 8:54:37 AM
Signed: 11/15/2024 8:54:41 AM
Electronic Record and Signature Disclosure:
Not Offered via DocuSign
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
Cheyenne Defee
cheyenne.defee@cityofdenton.com
Procurement Administration Supervisor
City of Denton
Security Level: Email, Account Authentication
(None)
Sent: 11/15/2024 8:54:43 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 11/14/2024 3:49:40 PM
Certified Delivered Security Checked 11/15/2024 8:54:37 AM
Signing Complete Security Checked 11/15/2024 8:54:41 AM
Completed Security Checked 11/15/2024 8:54:43 AM
Payment Events Status Timestamps