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6922 - Informal Amendment 2 Executed Docusign Transmittal Coversheet File Name Purchasing Contact Contract Expiration DocuSign Envelope ID: A2D8AF39-58CC-49DC-B4E5-1F2E59D41B62 12/18/2023 Gabby Leeper 6922 Stop Loss Insurance UHIC AMEND (07/06) UnitedHealthcare Insurance Company A Stock Company 185 Asylum Street, Hartford, Connecticut Phone: 1-877-294-1429 AMENDMENT NO. 9 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, 2023. UnitedHealthcare Insurance Company William J Golden, President Timothy J. Burch, Secretary ACCEPTED BY: Title: Date: DocuSign Envelope ID: A2D8AF39-58CC-49DC-B4E5-1F2E59D41B62 7/14/2023 Deputy Director, Risk & ComplianceBuyer 7/14/2023 UHIC AMEND (07/06) DocuSign Envelope ID: A2D8AF39-58CC-49DC-B4E5-1F2E59D41B62 UHIELIP (07/06) 1 SCHED UnitedHealthcare Insurance Company A Stock Company 185 Asylum Street, Hartford, Connecticut Phone: 1-877-294-1429 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-715130AL Effective Date: January 1, 2023 Administrator: United HealthCare Services, Inc. Coverage specified herein is applicable only during the Policy Period from January 1, 2023 through December 31, 2023, 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, 2023 and Paid from January 1, 2023 through December 31, 2023. 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 Specific Excess Loss Premium: $188.85 per subscriber per month AGGREGATE EXCESS LOSS INSURANCE Benefit Period: Covered Expenses Incurred from January 1, 2014 through December 31, 2023 and Paid from January 1, 2023 through December 31, 2023. 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: $28,863,913 or 95% of the first Monthly Aggregate Deductible amount times 12, whichever is greater DocuSign Envelope ID: A2D8AF39-58CC-49DC-B4E5-1F2E59D41B62 UHIELIP (07/06) 2 SCHED Maximum Covered Expenses per Covered Person accumulating toward the Maximum Aggregate Benefit: $185,000 Monthly Aggregate Factors: $1,673.44 per subscriber Aggregate Excess Loss Premium: $4.82 per subscriber per month The premium amount reflected above includes the following: • Aggregate Accommodation Endorsement DocuSign Envelope ID: A2D8AF39-58CC-49DC-B4E5-1F2E59D41B62 Certificate Of Completion Envelope Id: A2D8AF3958CC49DCB4E51F2E59D41B62 Status: Completed Subject: ***Purchasing Approval*** 6922 Stop Loss Insurance Amendment 2 Source Envelope: Document Pages: 5 Signatures: 2 Envelope Originator: Certificate Pages: 5 Initials: 1 Gabby Leeper AutoNav: Enabled EnvelopeId Stamping: Enabled Time Zone: (UTC-06:00) Central Time (US & Canada) 901B Texas Street Denton, TX 76209 Gabby.Leeper@cityofdenton.com IP Address: 198.49.140.104 Record Tracking Status: Original 7/13/2023 12:33:14 PM Holder: Gabby Leeper Gabby.Leeper@cityofdenton.com Location: DocuSign Signer Events Signature Timestamp Gabby Leeper gabby.leeper@cityofdenton.com Buyer City of Denton Security Level: Email, Account Authentication (None) Completed Using IP Address: 198.49.140.104 Sent: 7/13/2023 12:36:11 PM Viewed: 7/13/2023 12:36:21 PM Signed: 7/13/2023 12:36:43 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: 198.49.140.104 Sent: 7/13/2023 12:36:45 PM Viewed: 7/14/2023 1:25:26 PM Signed: 7/14/2023 1:26:28 PM Electronic Record and Signature Disclosure: Not Offered via DocuSign Deby Skawinski Deby.Skawinski@cityofdenton.com Deputy Director, Risk & Compliance Security Level: Email, Account Authentication (None)Signature Adoption: Pre-selected Style Using IP Address: 198.49.140.10 Sent: 7/14/2023 1:26:29 PM Viewed: 7/14/2023 1:32:31 PM Signed: 7/14/2023 1:32:40 PM Electronic Record and Signature Disclosure: Accepted: 7/14/2023 1:32:31 PM ID: f535d3be-1b72-45b1-a5dd-484e7f40596f Gabby Leeper gabby.leeper@cityofdenton.com Buyer City of Denton Security Level: Email, Account Authentication (None) Signature Adoption: Pre-selected Style Using IP Address: 198.49.140.104 Sent: 7/14/2023 1:32:41 PM Viewed: 7/14/2023 1:36:34 PM Signed: 7/14/2023 1:36:39 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: 7/14/2023 1:36:40 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 7/13/2023 12:36:11 PM Certified Delivered Security Checked 7/14/2023 1:36:34 PM Signing Complete Security Checked 7/14/2023 1:36:39 PM Completed Security Checked 7/14/2023 1:36:40 PM 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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