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Home My WebLink About8339 - Amendment 3 Executed DocuSign Transmittal Coversheet File Name Purchasing Contact Docusign Envelope ID: 63B9CD9A-2047-4B9C-A743-5B7C367600D2 Christina Dormady 8339 - Individual and Aggregate Stop Loss Insurance Amend 3 United HealthCare Insurance Company 185 Asylum Street Hartford, CT 06103-3408 AMENDMENT NO: Amendment to be attached to and made a part of Group Policy No. UHIC-601546, issued by United HealthCare 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, 2026. Docusign Envelope ID: 63B9CD9A-2047-4B9C-A743-5B7C367600D2 UnitedHealthcare Insurance Company A Stock Company 185 Asylum Street Hartford, Connecticut 06103-3408 1-800-357-1371 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: UHIC-601546 Effective Date: 1/1/2026 Administrator: United HealthCare Services, Inc., Bind Benefits, Inc., d/b/a Surest and any entity to which it delegates administrative services, OptumRx Coverage specified herein is applicable only during the Policy Period from: 1/1/2026 through 12/31/2026 , and is further subject to all terms and conditions of this Policy. Specific Excess Loss Insurance: Yes Benefit Period: Covered Expenses Incurred from 1/1/2014 through 12/31/2026 and Paid from 01/01/2026 through 12/31/2026. Specific Deductible per Covered Person: $185,000 Specific Percentage Reimbursable 100 % Maximum Specific Benefit per Covered Person: Unlimited Specific Excess Loss Insurance includes: Medical, Stand Alone Prescription Drug Program Covered Units Rates Composite $273.34 Docusign Envelope ID: 63B9CD9A-2047-4B9C-A743-5B7C367600D2 Aggregate Excess Loss Insurance: Yes Benefit Period: Covered Expenses Incurred from 1/1/2014 through 12/31/2026 and Paid from 01/01/2026 through 12/31/2026. Aggregate Excess Loss Insurance includes: Medical, Stand Alone Prescription Drug Program Aggregate Percentage Reimbursable: 100 % Maximum Aggregate Benefit: $ 1,000,000 Minimum Annual Aggregate Deductible: $39,691,508 or 95% of the first Monthly Aggregate Deductible amount times 12, whichever is greater. Maximum Covered Expenses per Covered Person accumulating toward the Maximum: $185,000 Monthly Aggregate Factors: Covered Persons Medical Prescription Drugs Dental Vision Composite $2,006.75 Included n/a n/a Aggregate Excess Loss Premium: $5.78 per Employee per month. Aggregate Accommodation Endorsement Premium: Included SPECIAL CONDITIONS: No New Laser/40% Rate Cap Applies to the renewal period of 1/1/2027 - 12/31/2027. Docusign Envelope ID: 63B9CD9A-2047-4B9C-A743-5B7C367600D2 1/23/2026 1/23/2026 Certificate Of Completion Envelope Id: 63B9CD9A-2047-4B9C-A743-5B7C367600D2 Status: Completed Subject: ***Purchasing Approval*** 8339 - Individual and Aggregate Stop Loss Insurance Amendment 3 Source Envelope: Document Pages: 4 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: 198.49.140.104 Record Tracking Status: Original 1/21/2026 9:37:24 AM 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: 198.49.140.104 Sent: 1/21/2026 9:46:00 AM Viewed: 1/21/2026 9:46:11 AM Signed: 1/21/2026 9:46:38 AM 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: 198.49.140.104 Sent: 1/21/2026 9:46:40 AM Viewed: 1/22/2026 7:17:50 AM Signed: 1/22/2026 7:18:54 AM Electronic Record and Signature Disclosure: Not Offered via Docusign Megan Gilbreath Megan.gilbreath@cityofdenton.com HR Director City of Denton - Human Resources Security Level: Email, Account Authentication (None) Signature Adoption: Pre-selected Style Using IP Address: 2600:100c:b289:d0fc:c469:977:c559:6868 Sent: 1/22/2026 7:18:56 AM Viewed: 1/23/2026 4:34:49 PM Signed: 1/23/2026 4:57:16 PM 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: 2600:6c56:7e08:2fad:7d5b:4f3c:13e:494 Signed using mobile Sent: 1/23/2026 4:57:17 PM Viewed: 1/23/2026 4:57:48 PM Signed: 1/23/2026 4:57:55 PM 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: 1/23/2026 4:57:56 PM Electronic Record and Signature Disclosure: Not Offered via Docusign Sara Kjos Sara.kjos@cityofdenton.com Assistant Director of Human Resources Security Level: Email, Account Authentication (None) Sent: 1/23/2026 4:57:56 PM 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 1/21/2026 9:46:00 AM Certified Delivered Security Checked 1/23/2026 4:57:48 PM Signing Complete Security Checked 1/23/2026 4:57:55 PM Completed Security Checked 1/23/2026 4:57:57 PM Payment Events Status Timestamps