HomeMy WebLinkAbout1989-0392646L
AN ORDINANCE AUTHORIZING THE MAYOR TO EXECUTE AN APPLICATION TO
ENTER INTO A CONTRACT BETWEEN THE CITY OF DENTON AND SOUTHERN
RISK SPECIALISTS INC FOR A STOP LOSS POLICY, AND PROVIDING FOR
AN EFFECTIVE DATE
THE COUNCIL OF THE CITY OF DENTON HEREBY ORDAINS
SECTION I That the Mayor is authorized to execute an
appl caation to enter into a contract between the City of Denton
and Southern Risk Specialists Inc for a stop loss policy, under
the terms and conditions contained in the specimen of said
policy, a copy of which is attached hereto
SECTION II That this ordinance shall become effective
imme ate y upon its passage and appro al
PASSED AND APPROVED this the ;ay of Pj2h4joL , 1989
ATTEST
i
APPROVED AS TO LEGAL FORM
DEBRA ADAMI DRAYOVITCH, CITY ATTORNEY
BY--
I
LEXINGTON INSURANCE COMPANY
200 State Street
Boston Massachusetts 02109
EXCESS LOSS INDEMNITY
APPLICATION
The Applicant is applying for a policy providing the insurance specified below
I Name of Applicant CITY OF DENTON
Address 324 E McKinney, Denton, Texas Zip Code 76201
Type of Business Municipality
Other Locations Yes No X
If yes specify all locations
2 Plan Administrator August International
Address 1059 N. Central #400, Dallas. Texas Zip Code 75206
3 Broker Southern Risk Specialists Inc
Address 1999 Bryan Straet_ Suite 1820. Dallas, TX Zip Code 75201
4 Initial Enrollment 705 Minimum Enrollment
(A) SPECIFIC EXCESS INSURANCE
(1)
Specific Retention Amount per Covered Person for the
$
60,000
Policy Year
(2)
Limit of Liability
$
940,000
(3)
Reimbursement Factor
100 %
(4)
Monthly Premium Rates Payable per Covered
Unit for the Policy Year
❑ Composite Basis ❑ Single/Family Basis
$
9 20
(5)
Monthly Optional Transplant Endorsement Rate
N/A
Payable per Covered Unit for the Policy Year
$
SA IOI1887
(B) AGGREGATE EXCESS INSURANCE
(1) Monthly Aggregate Retention Amount Factor
(2) Anticipated Annual Aggregate Retention Amount
(3) Minimum Aggregate Retention Amount
(4) Limit of Liability
(5) Reimbursement Factor
(6) Monthly Premium Rate Payable per Covered
Unit for the Policy Year
(C) MINIMUM PREMIUM
(D) COVERED BENEFITS
IN Medical ❑ Dental ❑ Weekly Indemnity
❑ Prescription Drugs ❑ Other
(E) PAYMENT BASIS
❑ Incurred and Paid ❑ Paid 13 Other 15
(F) Endorsements
❑ Optional Transplant ❑ Other
$ 288 68
$ 2,442,233
$ 2,075,897
$ 1,000,000
100
$ 2 93
$ 87,227
12 — 3 month Run In
5 Proposed Effective Date 3/1/89 subject to Lexington acceptance
6 Deposit of $ 37,759 is enclosed to apply to the first payment under the Policy if issued
i
Date at the day of , 19d�?
(Signawrc of Surplus Lines Licemee
Api
BY
TN,
s®utheen risk specialists inc.
telex 682 9273 1999 Bryan Street
telex 620 48087 Dallas Texas 75201
Com
CO1+WM. The Lexington Ineumnoe 0a1Wai1Y
INSURED CITY OF DEN=
ADDRESS 324 E MaMMY, DMUM, TEXAS 76201
COVER NOTE NMMM TERM EFFE(!1'IVE DATE EXPIRATION DATE
864 2234 60 DAYS 4/1/89 6 /1/89
Coverage is only applicable to the category for which a premium rate is
shown If no premium rate is shown, coverage is not provided for that
category
(A) SPECIFIC MME88 IIJBUPWICE
(1) Specific Retention Amount
for the Policy Year
(2) Limit of Liability
(3) ReimbUlsement Factor
(4) Monthly Rates Payable
for the Policy Year
(B)
per Covered Person
Composite
single
Family
(5) Monthly Optional Transplant Endorsement
Payable per Covered Unit for the Policy
$ 60,000
$ 940,000
100
$ 9 20
$
Rate
Year $ N/A
(1)
Monthly Aggregate Retention Amount Factor
$
288
68
(2)
Anticipated Annual Aggregate Retention Amount
$
2.442,233
(3)
Mininmmm Aggregate Retention Amount
$
2,075,897
(4)
Limit of Liability
$
1,000,000
(5)
Re=bursement Factor
100 $
(6)
Monthly Premium Rate Payable per Covered Unit
for the Policy Year
$
2 93/PER/EE/MD
(c) mnmux
PFamm
$
87.227
(D)
(X) Medical ( ) Dental () Weekly Indemnity () Prescription Drugs
(E) PAYMENP BABIS
( ) Incurred and Paid ( ) Paid (X) Other 15J12 - 3 MDNlii RUN IN
(F) ENDORSE UM
( ) Optional Transplant ( ) Other
(a) Conditions precedent to the binding of coverage Linder this Cover
Note *SEE PAS 2
(H) ADMINISTWOR OF BENEFIT PLAN
This Cover Note states the coverage provided by the company on the
date of issuance, subject to policy terms and conditions, and shall be
automatically cancelled and superseded by the Policy when issued In
no event shall this Cover Note remain in effect for a period in excess
of sixty days from the Effective Date specified above
♦♦
♦� AAA
multi -market professionals
BRANCHES IN HOUSTON & TULSA
(214) 220-6111
fax (214) 954 0094
Cancellation: This Cover Note may be cancelled by either the Insured
or the Company by advance written notice to the other In the event
of cancellation, the earned premium will be computed short rate if
Cancelled by the Insured and pro rate if cancelled by the ocupany.
ADDRESS 1999 BRYAN STREET, SUITE 1820, DALLAS, TMW 75201
Dated at SOUTHERN RISK SPECIALISTS this 19TH day of JANIAW 1989
i
riz Signature
* 1 Information that was requested on the proposal of 11/18/88
2 Surplus Lines Tax and Stamping Fee
U XINGTON INSURANCF (OMPANX
200 St III, StrLLt
Boston M tss uhuxtts 02109
EXCESS LOSS INDEMNITY POLICY
III eonvder tnon of the pavmLnt of premium the st.ttements to thL tpphL thon t eopv of "huh is ntILhLd to tnd
m tde t p utof this Pohcy utd subJeu to the, terms conditions tnd hnut tnons of this POItt) Lexington Insur lust
Comp un hLrem LIlled the Compam dots msurL
Insured
Pokes #
Address
IhehtstpnnuntolptLmtumtsdutan(—IliR
rhttorLtli EIILLtneDtteshownintheScheduletndallothu
pienuums ue due and pavablt is xt,11(PavmLnt of Premiunn provision "hilt the Pohts is to torte
ThL POkev Year shall hegtn ,Md LndV�1201 a m Sttndatd 7nnt it the address of thL pnnupil ofhLL of thL
N tmtd Insured
C >untLrstgned at By
AuthortzLd RLprtsentanve
SA 100/4 87
i — DI I INITIONS
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IINL DItL of this PohLv Ineludntt im unondnwlts to Such III In
III \1III PIANPAYMINISON \NIN( URRI1) \NDPVIDI3\SlSniein, loi IPohuNl.tl thetold unount
Of hcflLIIts to WhILh ( Olued Units od C o%LtLd PLISOns IILLOiIIL Ln[It [Lot undu thL PI to whjLLt to I 1111111 nunls of
this Polies Sueh unount of hLnLhtn sh III of InLludc the LILI hIL 1 vpl.nSLS mLurrLd on 01 110.rthL I ItLLnvL 1) uL
Of this PohLI ind p lid during the Polies Ye it Such unount of buHLhtS sh III not tnelucle dcduLnhlLS LoulStlr InLL
IIIIOIIiIh oI lnv oihu expenses od LI untS NhiLh irL not funlhudxJ uncle tIlL ILrins of the PI ill not sh ill it mLludL
LApL If SLs vN h lLh Ire rtimburs thh, tioni im othuunILL No Lost of L I it in p nnlLnt )r LxpLIISL of but Iuo [IS Sit I I I hL
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ILI nLS Is provided Dritls or LhLLks ISSULd Still] hL Lounted is unount', p rid ind thL D uL of INSIIL of L ILh di Ilt of
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this POhLv
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RLIL I1011 Amount ShoNn III thl SLhLdU1L NhlL h0I.1 is J11t1i
SPI ( 11 I( R1 11 N I ION \MOT NI MLUIs tIlL unount spLLlhLul ill thL SLhLLInk Nhich n Nli III ILrun d
till. A InILLI InSIITL l pu (OSLILLI Pl.IS II lot tilL P0110 NL IT
11A111 01 1 IABII Ill IIIL Ins IIIL unount spuihLd ill tIIL SLhLJuIL NhiLh r, thL nI lvnnunl p 1L IN, till lu till,
PohLv to thL N uncd InsulLd 101 thL PuIILv Nc u
RF IM13t1RSI MEN I I AC IOR 111L Ills tIlL pLrLLm I_L s110Nn Ill IIIL SLhLJLIIL NhILll Ndll dLt(InI1nL the doll u
(mount of thL Limn of Li thdhtN Nhieh %vill hL Pod to till, N Imu1 IIAHIILJ sLp a IIL Rl.11II1)LIIK.mLnl 1 IuoIS nI IN
Ipph L HLh to thL A�pLf- HIL I vLLss Instil HILL Ind SpeLIIIL F NUS, IIISUI HILL
NAM1 D INSLIRI D mL Ills thL InstilLd if imLd In this P(IIILv of illv Bust L St ihll,hLd by of III thL N unLJ InsuILJ
undu thL BLnLht 1'IIll
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IIISLIILd on the FHLLnN'L DItL to 12 01 d nI Stind fill I imL It IIIL iddiLss of the prmuP If othLL of thL N InuLl
InsulLd on IhL I xpinuon D nL is idundlLd in thL SLIILLIUll.
V( I IVF IY At WORK IIIL InN Thor thL LmploNLL is pertoundnt full IIIIIL III ILLId it duties of his of IlLr nofni d
oLLup lotion on the F ttLLtINL D HtL of this Polfev of on his or hu I ist ILLHi1 nil SLhLLhdLd Nod k d IL prior to thL L hLL
tnL DnL of this PohLN
10 FAT I Y DiSABL ED mL Ins th It the individu it 1S hoSPIt 11 umhnLd or is tin iblL to u1gaLL in the norm HI
ILtIvIILs of I pLrson in Lood hL till) of hkL iLL Ind sLx
LEXINGTON INSURANCI COMPANY
200 Stite SmR t
Boston M iss nhusettA U3109
SCHLDULL — EAeess I oss Indunnm Polu�
INSURED POI ICY #
ADDRESS EF I LC I IVE DAFF
LXPIRAI ION DAtI
INI FIAL ENROL LMFN I MINIMUM ENROLLMENT
C osu Ige Is only IPphe thle to (ho c itegor) for which I premium r Ite Is shown holow It no premuim rue is shown
caner Igc Is not provided forth It c ItegorN
(A) SPEUFIC FXCESS INSURANCF
(1) SpWfIL R, tendon Amount pu Covered Pelson for the POIILv Ye IF S
(2) Lnmit of Li ihtlm S
(1) ReimbursementI tctor
(4) Monthh Premium R Ite p IN ihlc p<r Cowed I Fill 101 ihL 13011e� }e IF
( ) (ompostte B INIs ( ) SnikleiF unlh 13INIs S _
(`) Monthh Option if Fi mNpl int I ndorsemuit R Fie P n Ible P I
C o«red Unrt hn the Pollen Ye IF S
a w� V
IRI \(I(IRI CrAI I I XC ESS INSLiRAN(I
�
1) 'Monthh lzgietlte Retenn0❑ An I ikRly®
(') AHelm ItLd Annu it aLLree Fie Re Anxwni ti
() Mnumum ALL.IeLite Retennon Amount S
(4) I inut of L I ihilits S
(s) Runthursunent F tetor
(6) Monthh PrcInnlm Rue PIN Ihle per Covered Uiut
loi the POIILV Ye it S
C) MINIMUM PREMIUM S
(D) COVERED BFNEIIFS
) Muhe It ( ) Dentif ( ) Wee6h IndeFiITIM ( ) Plcsuupuon DnIL ( Other
(F) PAN MFN F BASIS
) Inulrrcd Ind Pud ( ) Pcad ( ) WILT _
(I) I NDORSEMFN FS
) Option if Ir inspl mt ( ) Other
(G) ADMINISTRATOR OF BENI FIF PLAN
II — SPiCIFiC EXCFSS INSURANCE
A l hL Compatn will p IN SublLLt to thL terms Londhuon, Ind limit tuons of this POlIL% thL Speufu FxLts,
BtnCtII II Ins to the, N imed insured within sixh (60) d INS IItLr ILLLpt uu.c hs the ( omp ins of thL proof oI loss
Ifld proof of PnlnLnt of hLnLlits under the PI ui
If the SpLuftL FxLLSs BLnLht for the POIILs YLaror it ILtion thLILot is the BLnLtIt PI ut P nniunlS On An InLUIItd
And P lid B Isis for I (ObLILd Person ILss the Speuhc RLn ntion Amount multiplied by the Rumbursemun
I utol and not LxLeedmg the Limit of Li ibilrts speuht,CI under SpLuhL LxLLss insurance in the
Schedule
C It I Covered Person mcurs EhLible Expenses I smEle Speuhc RetLntion Amount shill ipply for such CON LILd
Peron to those Fligihle FxpLnseS which ILL incurred ind pud Llurml, the POlres NLIr
III — A(( Fit GAiI, EXCESS INSURANCE
A Aftcr the end of the Pola y Ye a term tuition or L InLLIt mon the Comp im will p iy to thL N umtd Insured the
ALtiAL� ILL FXLLS, Beneht If Ins within sixty (60) d rys titer th itConip illy S kept mLe of tht proof of loss and
proof of piymuntS of btnLfrh untie the Plin sublet to the 2rms conditions Ind limnutions of this
POI I U
B I he AggiLgltt FxLL,S Buuht for the Pohcs Ye it or triLuon thereof IS thL BLnLht Plan Pivnunts On An
InLUHcd And Pud B isis IcsS (I) thL Annual AggrLgate RLILntio❑ Amount Intl (Z) ihL SpecdlL ExLess Beneht
which h is been or will bL rumbursLd by the Compury undcr thL SpLuhL ExLLS, lnsurinLL mulupllul by thL
RLinihuisLmcnt I ictor Ind not LXLLuhnL tlIL [ nnft of Lt ihfhth SpcLihLd undo A&, ILLttL I sLLsS 1nsurInLL ni
thL SLhcdnlL
IN — I INil I XIION S OF (ONFR1( F
I I c ( onip Ins h is no iLsponsihilm oI nh1"NOS
unLlLI [hI, Pohcs w IunibunL duLuh Im CosLred KI ,In
of pioNidLi of protLS,Ion II oI nadlL II SL r Ins hLnLtIis whlLh [IiL A nnLd inSUIL(Ih IS IlO-Ld to PunIdc
unu..f IIIL (Lrm, of t1% PI in [hL ({n I uIIL It thilm IILrLIAMIL1 n t[i thL N ImLCI Inwud suhlLLt to ihL
ILrms Conditions and Inns uuin i e PoIILs
B II I C osLrLtl Puum Is not ALu P oI k or iS tot Ills DIS IhINd on thL [ IILLnsL D uL of thl, POIILv 1 h_ih1L
I xpLnu„h III include is xpuius sum rul dtu the d uL thL ulsuul Pu Son retulm to wort. full umL
oI thL lot it [)is thilitL `er d the ( oscrW PLrson HILLIS thL LhLihihh ILyuItLmLnt, of thL PI un
( ( osLi ILL of cSpLnuS for trL Itinuu of MLOt tl and NLrsou, C ondition, is hmilLd to S'_s 00000 in LSCLsS of
IhL SpLuhL RLtLnlio❑ Amount
N — F X( I I SIONS
1 his Polfcs will not iumhursL 0% N truLd InSUfCd for ans loss oI LspLu,L L ILISLd hs or rt,sultml from uis
oI TIIL following
I I xpLnsL,' mcuncd while thL PI in is not in tOILL
_ I xpcnsL, resulting from thL prosnion of wLekly mLomL hLnLIOS or im dcntit vision hL irmt, or prtscrlption
druC piogtam unILSS SpLuhL utly Lndorsed hLreon
3 L I iblhts issumLd hs thL Named Insured under my contr ILI or SLrvILe igrtLm,nt other th in thL PI in
4 1 XPLrnLS whILh ire bled upon my noncomP11mLL with Im IL�II sttttrtL or rLgullhon
s I cpLnSLs resulting from sLrvILLS or Supplies which ire not niLdIL ills nLLLss iry irL in LxLLSs of the usual and
Lustom irs Lh irgc for the IoL IIIty where IdminisLred or ILL in LxLLSS of the PI in hLnefuts
6 1 xpLnuS for my ILudLnt it bodily mlury or sieknLsS for wh]Lh the COWL-LI PLrson would bL LnhtlLd to
hLnehtS undcr my WorkCrS Compensation or OLcuP tuon it Dist Ise policy whLthcr or not such pohLy IS
ILILI Ills in forLL
7 ( ostof lhL admmistntion of cl urns orother servtL,(s) provIdLd by NIL idmmrstrItor Lonsultmt, ILLS orLxpLn
SLS of Ins litigation
8 With rLSPLLt to caLh COVLred PLrson who is ellgiblL for bcnLhtS undcr MLdicam I benLht othcrwiSL p ry ibic
under this Policy sh III bL rLduced by the amount of my Sm t a Me(hLin. benefit so th it the total reimbur
SunLntS hereunder on beh ill' of I C overed Person sh ill not LXLced onL hundred percent (1000/)) of the COVLred
Ptnon S iLtual expenses It will bL LonLlusrvely presumed th It L ILh COVLrtd Person LhgIbIL for benLhtS undcr
MtdiL ILL bLL lint LovLrLd for ill p irt% of MedIL ILL to which hL or slit, is unultd on thL L irhest possible d nL
Intl thcrL iter in unt unLd slch Lover ige in forLC
9 Expenses resulting from the commission of a crime or in illegal act
10 Expenses incurred in connection with a suicide or any intention illy self inflicted injuryor illness whether the
Covered Person were sane or insane when he or she commuted the act
1 I Expenses for experimental procedures drugs or research studies or for any services or supplies not considered
legal in the United States
12 Expenses incurred by a live organ donor unless the donor is a Covered Person under this Policy Expenses of a
live organ donor shall not be considered as eligible expenses of the organ recipient unless the donor is without
insurance in which case a maximum of $5000 shall be considered as Eligible Expenses of the
recipient
13 Expenses resulting from heart lung heart lung Iiyer or pancreas transplants unless specifically
endorsed hereon
Vi — POLICY TERMINATION
The Policy and all coverage hereunder will terminate upon the earliest of the following
A The Expiration Date of this Policy
B Termination Date under the terms of the Payment of Premiums provision
C Cancellation date under the terms of the Cancellation provision
D The Date of termination of the Plan or
E Cancellation of the agreement between the Named Insured and the administrator unless the Company h-is
prior to such cancellation (1) agreed in writing to the Named Insureds designation of a successor admmis
trator Ind (2) received a cop} of the agreement between the Named insured and the successor
administrator
ViI — CONDITIONS
PREMIUM The premium basis end rates for this Policy will be is st iced in tht Schedule Upon termination of this
Policy the earned premium shall be computed in accordance with the premium and expos ire basis shown in the
SLhLdule if the earned premium exceeds the premtu the N imcd Insured shall p-iy the excess to the Com
pany if less the Company sit ill return the unbar f the premium p uol to the Named insured subject to
he minimum premium d any shown m c
MINIMUM PREMIUM the m payable will be the amount shown in the Schedule or in the
eaent of termination or cancel) m of all monthly premium rates payable multiplied by the Minimum
Enrollment shown m the Sche ultiphed by the number of policy months
PAYMENT OF PREMIUMS Premiums ire due m advance on the first d iy of each month A period of fifteen (I s)
days will be granted for p iyment of each premium during which period the Policy will continue in force Should a
premium otherwise due not be p ud during such period this Policy will terminate without further notice on the date
the unpaid premium was due
DA1A REQUIRED The Named insured will in untain Idequite records accept ible to the Company and provide
ans inform ition required by the Company to admmistcr the 1301I y l he Company in iy periodically ex [mine ins
of the Named insureds records relating to the insurance under the Policy and any claims filed under the
Plan
Cl ERICAL ERROR Clerical error whether by the Named insured or by the Company in keeping any records
pert lining to the eoserage will not mvandatc coverage otherwise v ilidly in torcc or continue coverage otherwise
s [bolls terminated
AMENDMFNTS rO THE POLICY This Pohey may be amended at any time with the mutual consent of the
Company and the Named Insured
AMENDMENTS TO THE PLAN AND ADMINISTRATIVE AGREEMENT The Named Insured will provide
the Company with a copy of the Benefit Plan The Plan shall not be ch ingcd while this Policy Is in force withoutthe
prior writu n consent of the Company Notice of amendment to the PI in must be given to the Company in writing it
200 St ate Street Boston Massachusetts 02109 at least thirty one (3 1 ) of iys prior to the Effective Date of the amend
ment in the event that the Company does not consent to the amcnclmcnt the Company shall be liable to p ty
benefits hereunder as if the Plan had not been amended i urthermorc the N amcd inutred will provide the Corn
piny with I copy of the Named insured s written agreement Ind all imendments thereto with its Admmistritor
Ind the Named Insured agrees that a copy of any future amcnolmenrs to or ch mge in that igreemcnt shall be pro
vided to the C ompany prior to the tome it becomes efftctive
NO i IC E Ior the purpose of any notice required from the C omp Ins under the provisions of this Policy notice to
the Named insured shall be eonvdcred notice to the Admtnistrnor
MNIINISIR%IION OF (IAINISI NUIR IHF Pt AN
I I h, N un,d ImII1, I Sh III undut f6, it III timCS to unPlos till xnlus of fit AdmimStl nor Nho Sh III h,
I„m,d IhC A'lilt of Ill, Nlmul In uful
111, A IIIIIIIIstt rtoi 1,Un_ on 11111 III of the N unul InSt11, I Sh III
uPu I„ the ulnunlStl Ilion Ind I Ilusfiuutt of III shuns nd tint, fill ICUWI1,s old Lomputluon
01 Ill CI unlS
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Insm,d I hC N ImCd Insured Sh III ,00p,r It, fulls Ind do III thlnLS ills,, irs Ind ICyunCd tot Ill, Comp 111% to
purse, IM M1011 to tuos,r ltunst th, Ihnd Puts
\its unourltS I(.l.Ob,f,d hs tilt N im,d Insured PI in Admnustrlun or th, ( onlp firs In such MIMI Sh III hC
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w Inn of t ,h IVILC In IM P lit of this POlt,s or ,stop the Comp 11Is horn ISSUtII)L Im ntht und,r ill, turns of this
Poh,s not Shill the turns of this Poh,s hL wfivCd or,hntl.Cd Cxu,pt hs ,ndon,mun isSmd to Iolm I
pert of this Polt,o
ASSI(,NMI N I ASStgnm,nt of Intu,St undo this PoIICN Sh III not hind IhC ( onlP Ins Unul IIS,OIIt,nt IS,ndorud
hU,Ott it how,s(r the N IrnLLI Inun,d Sh III die Su,h msurinu dS IS Iftoldul M this POIICS Sh III ippls (1) to Ill,
N Iol,d Inwf,d S log of r,pr,Sutt Iin, IS the N Im,d Insured but onls wild, mini, within the stop, of 111s 01 hu
dUnLS IS SLILh Ind (2) will r,spCCt to th, PIOP,ns of ihC N Ifllul Inwr,d to th, puum h Isnt- ptop,r tunpot m
CUStods th,r,ol IS 111SWr,d hilt onls until ill, IPpolntm,nt Ind yu Ihh, Ilion of fill ',g if rLpr,S,nt fits,
CANCELLATION This Policy may be cancelled by the Named Insured by surrender thereof to the Company or
by mailing to the Company written notice stating when thereafter such cancellation shall be effective This Pohcy
may be cancelled by the Company by mailing to the Named Insured -it the address shown in this Policy written
nonce stating when not less than thirty (30) days thereafter such cancellation shall be effective The mailing of
notice shall be sufficient proof of notice The time of surrender or the effective date and hour of cancellation stated
in the noticesh II become the end of the Policy Period Dehvcryof such written notice either by the Named Insured
or by the Co pany shall be equivalent to mailing
if the Named Insured cancels earned premium shall be computed in accordance with the customary short rate.
table and proc dure if the Company cancels earned premium shall be computed pro rata Premium adjustments
may be made either at the time cancellation is effected or as soon as practicable after cancellation becomes effeL
five but payment or tender of unearned premium is not a condition of cancellation
LEGAL ACTION No action at law or m equity shall be brought to recover on this Policy prior to the expiration of
sixty (60) days after written proof of loss has been furnished in accordance with the requirements of this Policy No
such action shall be brought after the expiration of three (3) yelrs after the time written proof of loss is required to
be furnished
CONFORMITY WITH STATE STATUES if any time limitation of this Policy with respect to giving notice of
claim of furnishing proof of loss or bringing action is less than that permitted by the law of the state in which the
Named Insured resides such limitation is hereby extended to agree with the minimum period permitted by
such law
REPRESENTATIONS By acceptance of this Policy the Named insurLd agrees that the statements in the apphL i
tion and in the Schedule are his agreements and representations that this Policy is issued and continued in reliance
upon the truth of such representations and that this policy embodies all agreements existing between such Named
insured and the Company
SERVICE OF SUITS It is agreed that in the event of the f uluic of the Companv to pay inv [mount clalmcd to be
due hereunder the Company at the request of the Named insured will submit to the jurisdiction of any court of
competent jurisdiction within the United States and will comply with all the requirements necessary to give such
court jurisdiction and all in itters ansing hereunder sh ill be determmLd in accordancL with the Hw ind prauiLe of
such court
Further pursuant to any statute of any state territory o Psmc
t of the United States which makes provision
therefor the Company hereby designates the Sinn,,yy�mmissioner or Director of InsurmLe or other
Officer snecified for that nuroose in the statute or,.w----- I$ffice, as its true and lawful attorney upon whom
may be served any lawful process m an a i i �r�roceedmg instituted m any court of competent jurisdiction
by or on behalf of the Named incur n iciary hereunder insmg out of this contract of msunncL and
hereby designates Counsel Lexmg urance Company Legil Department 200 State Street Boston
M issachusetts 02109 or tits or her repr en tive as the person to whom said officer is authorized to in ul such pro
Less or a true copy thereof
IN WITNESS WHEREOF the Company has caused this Pohcy to bL signed by its PrLsidentand Secretary but this
Policy shall not be valid unless countersigned by i duly authorized reprLsentative of the, Comp my
44
Secretary
President
ENDORSEMENT
This endorsement effective l c r 1 A M forms a part of
ool �y No issued to
by LexIng6Ln Insurance Lo1+pary
Specific Run —In
It is hereby understood and agreed that in regard to Specific Excess
Insurance the total amount of 'Run -In' benefits to which Covered
Persons become entitled under this policy shall only include the
Eligible Expenses incurred on or after B/l/B8 and received by the
Administrator of the plan for paymen mere than 30 days prior to
the Effective date of coverage T ligible Expenses must be paid
during the Policy Year ofll,l/B 11/1/89 as defined in Section
I DEFINITIONS of this policy �®
It is also understood an ed that the provisions of Section Iy
L 4TFr10NS of Loveragt Fa shall be applied as of IF �l F+ rf
_1 cld oth Pr i a= +rla Etrec tl e r* cna F'rl
Authorized Represenlabve
ENDORSEMENT
This endorsement effective M forms a part of
policy No issued to
by Lexington Insurance Company
In consideration of the premium paid, the policy is amended to include the
following additional coverage in Section V-Exclusions, item 13
SPECIFIED ORGAN TRANSPLANT COVERAGE
Subject to the provisions, conditions, exceptions, reductions, and
limitations of the policy, Lexington Insurance Company agrees to reimburse
the Named Insured in excess of the Specific Retention Anount for 100/ of
Eligible Expenses resulting from or directly related to the completion of a
heart, lung, heart-lung, liver or pancreas human organ transplant
procedures This rider provides
coverage only for Eligible Expenses incurred
while this rider is in effect and paid dining the Benefit period
Lexington Insurance Company
surgical, storage, and tran
of a human organ used in ar
rider, subject to a maximum
completed
All benefits provided as st
maximum of S1,000,OUu
eimburse the Named insured for
directly related to the donation
: procedure covered under this
rach organ transplant procedure
,r are 5ubject to a lifetime
Benefit Period, as used herein, means file (5) days immediately prior to and
fifty-two (52) weeks immediately tollowing a completed organ transplant
procedure covered under this rider
If a Covered Person is an Employee who is not Actively At Work or if the
Covered Person is a Dependent who is hospital confined of totally disabled on
the Effective Date of this rider, no insurance benefits shall be provided
under this rider until he or she is no longer disabled
Totally Disabled, as used herein, means unable to perform the normal
activities of like age and sex in good health
While this rider is in effect, the coverage provided herein shall apply to
all current and new Covered units
�_. * tf
AUTHORIZED REPRESENTATIVE
LE INSTON INSURANCE C0MPANY
200 State Street
Boston, Massachusetts 02109
pill 3111
This Addendum is attached to and forms a part of the Application of
(Name of Applicant)
Listed below are the names of.
1) all employees of the Applicant who, at any time during the period commencing three calendar
months immediately prior to the Proposed Effective Date, are not "actively at work"*, and
(2) the followingiWW are "totally disabled"*** at any time during the period commencing three
calendar months immediately prior to the Proposed Effective Date
a) all dependents of all employees of the Applicant whether or not such employees are
"actively at work"* during the period specified in (1) above,
b) C O B R.A ** participants, and
c) C O B R A.** eligible participants
Also specified below for these individuals respective ailment(s) are their diagnosis current
status, prognosis, and charges to date under the Applipantrs "benefit plan"****
The Applicant hereby certifies that the discwOands
-below are complete and true to the
best of its knowledge and belief The Appli
representations and are made for the purpose
the coverage applied for in this Applioa
issued in reliance on the truth of
Lexington will notibe liable for any
"actively at work11* or who were known be
Application.
Disclosures (Uselreverse side for additional space, if needed, in listing of names, and
identify as 1, 2,(a), 2(b), 2(c), as appropriate)
that these statements
are its
Lmungton Tn,a„,�nce Company to issue
e Policy, if one is issued, will be
It is understood and agreed that
inSt=aons
red by persons who were known to be not
"totally disabled"*** and are not disclosed in this
*11actively at work" in this Application means that the employee is performing full time all
regular duties of his or her normal occupation
**C O B R A means the Consolidated onnibus Budget Reconciliation act of 1985
*** 11totally disabled" means that the individual is hospital confined or is unable to engage in
the normal activities of a person in good health of like age and sex
****"benefit plan" means the welfare benefits the Applicant has agreed to provide under a plan
of benefits for the Applicants employees and their dependents and for any other covered under
such plan
signature
Date
rifle