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HomeMy WebLinkAbout1987-1772038L NO 2 AN ORDINANCE ACCEPTING THE PROPOSAL OF WASHINGTON NATIONAL INSURANCE COMPANY FOR EXCESS INSURANCE FOR THE CITY'S HEALTH INSURANCE PLAN AND FOR LIFE INSURANCE FOR CITY EMPLOYEES, AUTHORLZING THE EXPENDITURE OF FUNDS THEREFOR, AND PROVIDING AN EFFECTIVE DATE WHEREAS, the City has advertised and accepted proposals for life nsurance coverage for its employees and for excess insurance for its health insurance program for City employees, and WHEREAS, the City Manager having recommended to the City Council that the proposal of Washington National for said insurance coverages be accepted as being the lowest and best proposal received by the City, NOW, THEREFORE, THE COUNCIL OF THE CITY OF DENTON HEREBY ORDAINS SECTION I. That the City hereby accepts the proposal of Washington National Insurance Company for excess stop loss insurance for the City's employee health insurance and for life insurance for its employees, a copy of which proposal is attached hereto and incorporated by reference herein T SECION II. That the expenditure of funds for such insurance coverag s is ereby authorized SECTION III That this ordinance shall become effective immediately upon its passage and approval PASSED AND APPROVED this the & day of October, 1987 RAY STUKENS, CAY6R— ATTEST APPROVED AS TO LEGAL FORM DEBRA ADAMI DRAYOVITCH, CITY ATTORNEY BY ` C Aggregate Deductible shall mean for the Initial Agreement Period the amount determined at the close of the Initial Agreement Period by the use of the Aggregate Deductible Formula set forth in Part III of this Agreement, for a Subsequent Agreement Period the amount determined at the close of that Subsequent Agreement Period by the use of the Aggregate Deductible Formula set forth np Part III or by the use of the revised Aggregate Deductible Formula then in effect for that Subsequent Agreement Period D Individual Deductible shall mean the amount of Individual Loss shown as the Deductible on the Addendum under Individual Stop Loss Specifications which must be paid under the Plan in any one Agreement Period for any one covered individual before the Company will reimburse the Plan Sponsor as set forth in Part II E Individual Loss for each Agreement Period shall mean only such amounts wluch were incurred by any one person covered under the Plan and actually paid by the Plan Sponsor in cash within the period of time indicated in the Addendum under Losses Eligible for Reimbursement in payment of the benefits specified in the Plan that are paid to one particular person or to his or her assignees in settlement of the claim made by that person Amounts are considered to be incurred on those days the service(s) or the supply(ies) are provided If included under this Agreement, Disability In come Benefit amounts are considered to be incurred during the days a Disability Income Benefit is payable under the Plan In no event shall Individual Loss include amounts paid after the termination of the Agreement F Aggregate Loss for each Agreement Period shall mean (1) such amounts which were incurred by all persons covered under the Plan and actually paid by the Plan Sponsor in cash within the period of time indicated in the Addendum under Losses Eligible for Reimbursement in payment of the benefits specified in the Plan to all persons covered under the Plan, or to their assignees, in settle ment of claims made by such persons (2) minus those amounts eligible for reimbursement under the Individual Stop Loss provision of this Agreement and (3) plus an amount equal to the Individ ual Stop Loss Premium payable to the Company by the Plan Sponsor Amounts are considered to be incurred on those days the service(s) or the supphes(ies) are pro vided If included under this Agreement, Disability Income amounts are considered to be incurred during the days Disability Income is payable under the Plan In no event shall Aggregate Loss in clude amounts paid after the termination of the Agreement G Individual Loss or Aggregate Lose shall at no time include extra contractual damages of any nature, compensatory damages or any punitive damages assessed against the Plan Sponsor and the Company shall not be liable for any such damages The Plan Sponsor hereby agrees to hold harmless the Company from any such damages assessed against the Plan Sponsor and also agrees that such damages will not be used to satisfy any Individual Loss Deductible or Aggregate Loss Deductible H Amounts actually paid shall mean the checks or drafts issued for payment of Individual Loss or Aggregate Loss and honored, but it shall not mean court cost penalties interest upon judgments or investigation expense adjustment expense, or legal expense The date of issue of each check or draft shall be considered the date of payment I Monthly Deductible Information shall mean that information needed to compute the Monthly De ductible amount as set forth in Part III of this Agreement or any revision of Part III which is then in force PART II INDIVIDUAL STOP LOSS AND AGGREGATE STOP LOSS PROVISION The Company in consideration of the payment by the Plan Sponsor of the Individual Stop Loss Premium and the Aggregate Stop Lose Premium required by the Company HEREBY AGREES TO REIMBURSE the Plan Sponsor for A The percent shown on the Addendum under the Individual Stop Loss Specifications of the amount by which the Individual Loss incurred by the Plan Sponsor in settlement of a claim for any one covered individual exceeds the Individual Deductible amount during a particular Agree ment Period, subject to an Individual Maximum Benefit for any one individual of the amount shown! on the Addendum under the Individual Stop Loss Specifications and B The percent, shown on the Addendum under the Aggregate Stop Lose Specifications of the amount by which the Aggregate Lose incurred by the Plan Sponsor exceeds the Aggregate De ductibile amount during each separate Agreement Period subject to the maximum reimbursement as shown on the Addendum under the Aggregate Stop Loss Specifications F16526 Page 2 of 7 E] Wasnington nationar INSURANCE COMPANY EVANSTON ILLINOIS 60201 INDIVIDUAL STOP LOSS AND AGGREGATE STOP -LOSS AGREEMENT EFFECTIVE DATE THE PLAN SPONSOR November 1, 1987 City of Denton STATE OF DELIVERY Texas INITIAL AGREEMENT PERIOD Beginning on November 1, 1987 Closing on October 31, 1988 SUBSEQUENT AGREEMENT PERIOD Beginning on November 1 and Closing on October 31 of each year thereafter during the continuance of this Agreement AGGREGATE STOP LOSS PREMIUM The amount shown on the Addendum under PREMIUMS will be payable on November 1, 1987 andAnnuallyon November 1 of each year thereafter until this Agreement is amended to revise the premium INDIVIDUAL STOP LOSS PREMIUM (See Part IV) Since the Plan Sponsor has established a welfare benefit plan for payment of certain eligible expenses on behalf of all persons for whom contributing employers accepted by the Plan Sponsor for coverage under this Plan are required to make contributions to the "Plan Sponsor's Welfare Benefit Plan" and all such persons eligible dependents, and Since the Plan Sponsor is desirous of limiting that portion of their liability under this welfare benefit plan which exceeds the Aggregate Deductible amount and the Individual Deductible Amount and Since Washington National Insurance Company is willing to reimburse the Plan Sponsor for a certain portion of that liability The Plan Sponsor and Washington National mutually agree to the following terms and conditions PART I DEFINITIONS Where the following words and phrases appear in this Agreement they shall have the respective meaning set forth below unless their context clearly indicates to the contrary, A Company shall mean Washington National Insurance Company B Plan shall mean the welfare benefit plan of the Plan Sponsor, a copy of this Plan is attached and labeled Article A and is hereby made a part of this Agreement The provisions of Article A (or Temporary Article A if a formal Plan Document is unavailable) that are pertinent to determine which individuals are to be covered under the Plan the time period they will be covered under the Plan and the benefits for which they are covered under the Plan will be considered pertinent to this Stop Loss Agreement The Plan Sponsor agrees that (A) all liabilities created by Article A (or temporary Article A if a formal Plan Document is unavailable) belong only to the Plan Sponsor and (B) Washington National's liability shall be limited to the reimbursement F16626 Page 1 of 7 B The sum of the first twei.a Monthly Deductible amounts will be the AGGREGATE DEDUCT IBLE, except that, regardless of such actual total, the minimum AGGREGATE DEDUCTIBLE amount shall not be less than 90% of the first Monthly Deductible amount multiplied by twelve C The MONTHLY DEDUCTIBLE FACTORS and the minimum AGGREGATE DEDUCTIBLE shall apply until the end of the Initial Agreement Period, unless changed by agreement between the Pla)i Sponsor and the Company during the Agreement Period as a result of a change in the Plan For Subsequent Agreement Periods the MONTHLY DEDUCTIBLE FACTOR and the minim m AGGREGATE DEDUCTIBLE will be determined by mutual agreement between the Plan Sponsor and the Company and set forth in an Addendum to this Agreement signed by the parties hereto D If this Stop Lose Agreement should terminate on any date other than the closing date of the Initial Agreement Period or of any Subsequent Agreement Period, there will be no pro -ration of the muµmum AGGREGATE DEDUCTIBLE On the contrary the entire mimmum AGGRE GATE DEDUCTIBLE or the total of Monthly Deductible amounts determined for such partial Agreement Period, whichever is greater, will be applied to determine the Company's liability for any partial Agreement Period PART IV THE INDIVIDUAL STOP LOSS PREMIUM The rates used to compute the first monthly Individual Stop Loss Premium for the Initial Agreement Period are set forth on the Addendum These rates shall apply until the end of the Initial Agreement Period unless changed by mutual agreement between the Plan Sponsor and the Company during the Agreement Period as a result of a chanlge in the Plan For Subsequent Agreement Periods, the rates used to compute each monthly Individual Stop Loss Premium shall be those mutually agreed upon by the Plan Sponsor and the Company The MONTHLY PREMIUM RATE COVERED PERSON UNIT and COVERED BENEFIT are shown on the Addendumlunder PREMIUMS To compute the monthly Individual Stop -Loss Premium, the number of COVERED PERSON UNITS covered under the Plan on the first day of that month in each category shown on the Addendum must be multiplied by the MONTHLY PREMIUM RATE shown opposite the category The monthly Individual Stop -Loss Premium shall be this product or the sum of these products depending on whether there is one or more than one category shown PART V CONTINUATION AND TERMINATION This Agreement will continue in force during the Initial Agreement Period and during each Subsequent Agreement Period subject to the Plan Sponsor's payment of premium at such rates as may be required by the Company and subject to termination as provided in Part VI or as set forth below This Agreement shall terminate immediately upon the occurrence of the first of the following (a) mutual consent by the Plan Sponsor and the Company, (b) discontinuance of the Plan by the Plan Sponsor, (c) any attempt by th$$ Plan Sponsor to amend the Plan without the prior written approval of the Company (d) adjudication of bankruptcy or insolvency of the Plan Sponsor, (a) upon nonpayment of any premium when due or (f) delegation of the Plan Sponsor's duties under this Agreement to a Thud Party Admimstrator/Claims Administrator which has not been approved by the Company Tins Agreement may also be terminated by written notice of either party to the other by registered mail but not less than thirty one days in advance of the termination date set out in such written notice PART VI YEARLY ADDENDUM Within thirty days after the Company's receipt of all the Loss data for the preceding Agreement Period, in the format required by the Company, the Company will issue and deliver to the Plan Sponsor a completed Addendum to this Agreement indicating the terms for the renewal Agreement Period This Addendum shall be signed in duplicate by the Plan Sponsor and an executed copy returned to the Company If the Plan Sponsor should)) refuse to accept such Addendum for this Agreement Period and fail to execute and deliver the said Addendum and any additional premiums due to the Company by the thirtieth day after the date the Addendum is ailed to the Plan Sponsor, this entire Agreement will be deemed to have terminated at the close of the preceding Agreement Period, and the Company shall thereupon refund the Premiums paid for this Agreement Period The Plan Sponsor agrees to return any claims amounts reimbursed for this Agreement Period i F16526 Page 4 of 7 The Company at its own election and expense shall have the right to participate with the Plan Sponsor in the defense or appeal of any action, suit, or proceeding in which it may, in its judgment, become involved The Company shall have no obligation to defend the Plan Sponsor in any action arising under the Plan Sponsor s welfare benefit plan With regard to the AGGREGATE STOP LOSS the Company shall have no obligation to make payment to the Plan Sponsor until the thirtieth day following the Plan Sponsor s submission of a claim to the Company containing all necessary Aggregate Loss data and all Monthly Deductible Information for a particular Agreement Period With regard to the INDIVIDUAL STOP LOSS the Company shall have no obligation to make payment to the Plan Sponsor until the thirtieth day following the Plan Sponsor's submission of a claim to the Company containing any necessary data regarding an Individual Loss which has exceeded the Individual Deductible If the Addendum indicates Actively at Work is required then Individual Loss or Aggregate Loss as used herein will not include amounts of loss incurred by any person covered under the Plan or loss paid for by the Plan Sponsor unless the covered person was actively at work on the later of 1 The effective date of this Agreement or 2 The first day the individual is eligible for coverage under the Plan For a covered person not actively at work on the later of these two dates, only those losses which were incurred by such person on or after the date the covered person is again actively at work will be included under the meaning of Individual Lose or Aggregate Loss An employee is actively at work if he or she is working full time at his or her regular job or if the date in question is not a day when the employee is required to work then the employee must be able to work full time at the regular place of employment A dependent or a retired person is actively at work if, on the date in question he or she is not hospital confined for at least one day immediately prior to that date and is able to perform his or her normal duties and activities PART III THE AGGREGATE DEDUCTIBLE FORMULA The formula for and the factors used to compute the AGGREGATE DEDUCTIBLE for the Initial Agree ment Period are established as of the Effective Date of this Agreement The formula for and the factors used to compute the AGGREGATE DEDUCTIBLE for any Subsequent Agreement Period shall be established as described in Section C below of this Part The AGGREGATE DEDUCTIBLE shall be determined at the end of the Agreement Period by use of the following formula method, and factors unless revised as set forth in Section C below, of this Part The factors are shown on the Addendum under MONTHLY DEDUCTIBLE FACTORS They include the COVERED BENEFIT COVERED PERSON UNIT and the MONTHLY DEDUCTIBLE FACTOR A Starting with the first month of the Agreement Period, the number of COVERED PERSON UNITS covered under the Plan on the first day of that month in each category shown on the Addendum will be multiplied by the factor shown opposite the category The Monthly Deductible amount shall be this product or the sum of these products depending on whether there is one or more than one category shown, except that (1) in the event of a strike, lockout or work stoppage caused by any disagreement between an employer and all or certain persons covered under the Plan the number of COVERED PERSON UNITS used to compute the Monthly Deductible Amount in the month immediately preceding such strike lockout or work stoppage will be used to determine the Monthly Deductible amount for the month or months during which the strike lockout or work stoppage exists (2) in the event of a reduction of COVERED PERSON UNITS regardless of the reason the Monthly Deductible amount shall reduce no more than 6% from the month immediately preceding the one in which the reduction occurs and no more than 6% additionally each month thereafter during the continuance of the reduction F16526 Page 3 of 7 PARTIX TAXES The Company shall be held harmless by the Plan Sponsor from any state premium taxes which the Company may incur with respect to claims paid (as distinct from the prenuums paid to the Company by the Plan Sponsor) under the Plan Sponsor's Plan, and the Plan Sponsor shall reimburse the Company annually for such tax expense if any, as determined by the Company PART X PAYMENT OF PREMIUMS The Plan Sponsor shall remit all premiums as required by the Company to the Company at its Home Office in Evanston, Illinois Except as otherwise provided under the Section entitled "Grace Period, 'this Agreement shall automatically terminate if any premium is not paid when due PART XI GRACE PERIOD A grace period of thirty one (31) days without interest charge is allowed for the payment of every premium after the first PART XII DATA The Plan Sponsor shall maintain such records as are reasonably required by the Company and shall furnish to the Company all pertinent data with respect to persons covered under the Plan The Company shall have the right to inspect the records of the Plan Sponsor at reasonable intervals during business hours for any purpose relating to this Agreement PART XIII MODIFICATION Upon written request by the Plan Sponsor and with the consent of the Company this Agreement may be modified in writing without notice to or consent by any persons covered under this Plan Only the President a Vice President or the Secretary of the Company is authorized to modify this Agreement No other person has the authority to change this Agreement or to waive any of its provisions PART XIV PARTIES TO AGREEMENT This Agreement 1s only between the Plan Sponsor and the Company and this Agreement shall not create any right or legal relation whatever between the Company and any covered person or beneficiary under the Plan Sponsor 9 Welfare Plan PART XV OVER REIMBURSEMENT The Plan Sponsor agrees that should the Company over reimburse Aggregate Losses due either to clerical error or lack of information on Individual Loss(es) such over reimbursement will be credited towards any re imbursements due to Individual Loss(es) The Plan Sponsor further agrees that should such over reimburse ment exceed any reimbursements due to Individual Loss(es), this excess will be refunded to the Company PART XVI ARBITRATION All disputes between the parties to this Agreement upon which an amicable understanding cannot be reached may be decided by arbitration The Court of Arbitrators which is to be held in the city where the Home Office of the Plan Sponsor is domiciled, shall consist of three arbitrators familiar with employee benefit plans One of the arbitrators shall be appointed by the Plan Sponsor one by the Company and the third shall be selected by the first two appointees prior to the beginning of the arbitration Should the two arbitrators be unable to agree upon the choice of a tlurd the appointment shall be left to the President or any Vice President of the American Arbitration Association The arbitrators are empowered to decide all questions or issues and shall be free to reach their decision by application of principles of equity and customary practices of the insurance and reinsurance industry rather than by strict application of all rules of evidence and law They shall decide by a majority of votes and there will be no right of appeal from their written decision The cost of arbitration, including the fees of the arbitrators shall be borne by the losing party unless the arbitrators shall decide otherwise F16526 Page 6 of 7 PART VII PLAN CHANGES The Plan Sponsor shall promptly furnish the Company with all proposed Plan amendments endorsements, or riders If any change in the Plan if effected shall in the opinion of the Company increase the risk assumed by the Company, the Company shall have the option of notifying the Plan Sponsor of (a) an increase in the MONTHLY DEDUCTIBLE FACTORS and the nummum Aggregate Claim Deductible to be effective for the Agreement Period in which such change becomes effective and (b) an increase in the Individual Stop Loss Premium Rate and the Individual Stop Lose Deductible to be effective for the remainder of the Agreement Period in which such change becomes effective Upon the written agreement of the Plan Sponsor to the increases, an executed copy of such agreement, endorsement or rider shall be returned to the Company within 30 days of the effective date and shall be made a part of Article A and thereafter be considered as a part of the Plan If written acceptance is not provided to the Company within thirty days of notification from the Company the change will not be effective as part of this Agreement until the first of the month following the return of the written acceptance If any change in the Plan shall not in the opinion of the Company increase the risk assumed by the Company if that change were to become effective the Company shall so notify the Plan Sponsor If the Plan Sponsor sends an executed copy of this amendment, endorsement, or rider to the Company for attachment to Article A the Plan will be deemed so changed as of the effective date shown on such amendment, endorsement or rider PART VIII DUTIES OF THE PLAN SPONSOR The parties agree that the Plan Sponsor shall have the following duties and obligations A The Plan Sponsor shall be responsible for auditing and calculating and paying all claims, preparation of periodic reports including but not limited to monthly reports of the number of COVERED PERSON UNITS by category, and shall maintain and make available to the Company at all times such information as the Company may reasonably require for proof of payment of Individual Loss and Aggregate Loss by the Plan Sponsor B The Plan Sponsor will maintain a record of any and all amounts paid in excess of payments required by the provisions of the Plan C The Plan Sponsor agrees to pay all claims within thirty days of the time that proofs of claims are adequate to the extent that payment can properly be made Failure of the Plan Sponsor to pay such claims within the time limit (thirty days) shall cause any such claim to be excluded from counting toward the satisfaction of any Individual Deductible or AGGREGATE DEDUCTIBLE amount D The Plan Sponsor agrees to pay proper claims made by persons covered under this Plan and that funds as necessary will be provided for this purpose Failure of the Plan Sponsor to provide funds when needed for such timely payment will cause the Agreement to immediately lapse the Grace Period will be considered satisfied and the AGGREGATE DEDUCTIBLE and any Individual Deductible will be considered as not satisfied E The Plan Sponsor shall prepare and submit to the Company on a monthly basis a report of the total of all claims paid during such month and a report of the total number of COVERED PERSON UNITS in each category described on the Addendum under the PREMIUM section and the MONTHLY DEDUCTIBLE FACTOR section The Plan Sponsor shall maintain such other records as are reasonably required by the Company and shall furnish them to the Company upon request The parties also agree that the Plan Sponsor may retain a Third Party Admimstrator/Claims Admimstrator, that has been approved by the Company to perform any or all of the above -listed duties If the Plan Sponsor delegates duties under this Agreement to an approved Third Party Admmmstrator/Claims Administrator, the Plan Sponsor shall submit the Agreement between it and the Third Party Admimstrator/Claims Admimstra for to the Company This Third Party Admimstrator/Claims Administrator shall be retained and compen sated for administrative and claims paying services by the Plan Sponsor and shall not be considered as the agent of the Company for administrative and claims paying services Should the Plan Sponsor desire to change Third Party Administrator/Claims Administrator while this Agreement is in effect the new Third Party Admmmstrator/Claims Admimstrator must be approved by the Company and the Agreement with the new Third Party Admimstrator/Claims Administrator must be submitted to the Company F16526 Page 5 of 7 IN WITNESS WHEREOF, the Plan Sponsor and the Company have by their respective officers caused this Agreement to be executed and delivered on the dates shown below, replacing and superseding all prior agreements City of Denton the Plan Sponsor) 10 Title // Date ( r_/ Washington National Insurance Company zr7= By Title Senior Vice President o Date January 19, 1988 F16526 Page 7 of 7 AGREEMENT AMENDMENT The Company and City of Denton (Plan Sponsor) agree that effective on November 1 , 1987 the items on the attached page(s) which follow be added to and made a part of the Individual Stop Loss Agreement which was effective on No_vemhpr 1 . 1 QR7 Except as expressly stated this Amendment does not waive or extend any of the other provisions of said Agreement This Amendment expires with the Agreement City of Denton PLAN SPONSOR 1 0 / V Signature AI,� Tic U Title Signed at —i Date WASHINGTON NATIONAL INSURANCE COMPANY By Signature Senior V1re President A Title Evanston, IL January 19, 1988 Signed at Date F16632 (l 87) Except as expressly stated, this Amendment does not we've alter or extend any of the other provisions of said Agreement This amendment expires wlth the Agreement City of ELAN SPONStOIi / Signature U U T,— ,z A Signed at Date WASHINGTON NATIONAL INSU4ANCE COMPANY IRx — A; Signature Senior Vice President�S This Evanston, IL January 19, 1988 Signed at Date F16527 (1 87) AMENDMENT City of 11/1/87 The Company and Denton (Plan Sponsor) agree that effective on the following will be added to and made part of the Individual Stop Loss Agreement Notwithstanding anything in the Agreement for the contrary amounts actually paid by the Plan Sponsor in payment of benefits specified in the Plan for purposes of calculating Loss shall not include the following 1 Benefits covered by any Workers Compensation or Occupational Disease Law whether or not such policy is in force 2 Benefits which are not eligible expenses under the terms of the Plan, 3 Benefits paid under the Plan which are in excess of usual and customary charges for the locality where administered 4 Benefits paid under the Plan for any Employee or Dependent whose evidence of good health as a Late Applicant (as defined by Washington National Insurance Company) is not satisfactory to Washington National, 6 Benefits paid for charges or treatment not required because of an accidental injury or illness or not necessary to the care or treatment of such accidental injury or illness 6 Benefits paid for charges or treatment not recommended and approved by a physician or practitioner whose inclusion in the term "physician" is required by law, 7 Benefits paid under the Plan which would not have been paid if benefits had been coordinated under the provisions of the National Association of Insurance Commissioners Model COB Guidelines as amended from time to time 8 Benefits paid for losses which are due to war or any act of war whether declared or undeclared, 9 Benefits paid for treatment for cosmetic purposes or for cosmetic surgery, Except cosmetic treat ment or surgery due solely to a An accidental bodily injury which occurred while the individual was covered under the plan, or b Surgical removal of all or part of the breast tissue as a result of an illness, or c Correct a congenital birth defect of an individual who was covered under the Plan on the date of his of her birth 10 Benefits paid for services of a person who usually lives in the same household as the covered individual or who is a member of his or her immediate family or the family of his or her spouse 11 Benefits paid for any procedure that is deemed to be experimental or investigational in nature by an appropriate technological assessment body established by any state or Federal government, 12 Benefits paid for which the Plan Sponsor is not legally obligated to pay These would include but not be bruited to deductibles coinsurance and amounts in excess of maximums in the Plan, 13 Benefits paid for a mental or nervous condition or for any substance abuse condition which for any covered Individual exceed the lesser of a The maximum(s) in the Plan or b $60 000 during any Agreement Period P16527 over (1 87) ARTICLE A The attached pages are Article A, the Plan Sponsor a Plan D�ocu ent The fip1� Sponsor certifies that the Covered Benefits described therein were first in effect on November 1, 198 The attached pages replace those which were previously identified as Article A or Temporary Article A It is the intent of both parties to this Stop Loss Agreement that any reference in this Article A to the prior group insurance company, no matter how named shall be deemed to mean 'Plan Sponsor Any and all use of terms referring to "insured or "insurance shall mean coverage under the Plan Sponsor a Plan City of Denton PLAN SPONSOR a/ Signature Q Tale Signed at V Date WASHINGTON ATI AL INSURANCE COMPANY By Signature Senior Vice President 0 J Title Fvancion IT January 19 1988 Signed at Date F16531 7 MONTHLY DEDUCTIBLE . r+CTORS (USED TO COMPUTE THE AUGREGATE DEDUCTIBLE) COVERED COVERED PERSON UNIT MONTHLY DEDUCTIBLE FACTOR BENEFIT $106 88 Medical Employee 99 12 Medical Medical Spouse Child(ren) 62 70 Medical Family 136 99 8 PREMIUMS a Aggregate Stop -Loss $ 9.075 (Annual) b Individual Stop Loss COVERED COVERED MONTHLY BENEFIT UNIT PREMIUM RATE Medical Employee 3 3— Medical Dependent 9 Agreement ,Period to which this Addendum is applicable 88 Begins NypmbeE 1 ct 19 87 and Ends October 31 st 19 If the effective date of this Addendum is after the beginning of the Agreement Period this Addendum will replace and,aupersede any other Addendum for the same Agreement Period for the time period beginning with the effective date of this Addendum and ending with the end of the Agreement Period 10 Full Legal name and address of Third Party AdnumstratorlClaim Administrator Coordinated Benefits Systems ❑ None 6301 Gaston Ave Suite bbO Dallas -Texas 75214 City of Denton PLAN SPONSOR By Signature 7i —7 Title Signed at Date F16529 WAS HI N ATIONAL INSURANCE COMPANY By Signature Senior vice President�S Title Evanston, IL January 19, 1988 Signed at Date (1 87) INDIVIDUAL STOP -LOSS AND AGGREGATE STOP -LOSS ADDENDUM 1 PLAN SPONSOR Full Legal Name City of Denton Street Address 324 E McKinney City State and Zip Code Denton, Texas 76201 2 AGREEMENT EFFECTIVE DATE 11-1-87 3 Aggregate Stop Loss Specifications ADDENDUM EFFECTIVE DATE 11-1-87 Minimum Maximum Deductibles_ 760,500 Percent 100 % Reimbursements 1,000.000 4 Individual Stop Loss Specifications Deductible $ 60 , 000 Percent 6 COVERED BENEFITS a INDIVIDUAL STOP LOSS ►:1 ■ ■ Medical Maximum 100 % Benefit s 250,000 6 LOSSES ELIGIBLE FOR REIMBURSEMENT b AGGREGATE STOP LOSS ® Medical ❑ Dental ❑ Vision ❑ RX/Drugs ❑ Disability Income ri a ❑ I&P 12/12 which means the Losses were Incurred and Paid within the Agreement period for the Initial Agreement Period For subsequent Agreement Periods, Paid within the Agreement Period and Incurred on or after effective date of the Agreement Actively at work is required b ❑ I&P 12/15 which means the Losses were Incurred within each Agreement Period and Paid within that Agreement Period plus the 3 months following the end of that Agreement Period Actively at work is required c ❑ DSR 12/12 which means the Losses were Incurred and Paid within the Agreement Period for the Initial Agreement Period For subsequent Agreement Periods Paid within the Agreement Period and Incurred on or after effective date of the Agreement d ❑ DSR 12/15 which means the Losses were Incurred within each Agreement Period and Paid within that Agreement Period plus the 3 months following the end of that Agreement Period e ® PAID which means the Losses were paid within each Agreement Period Initial Agreement Period includes Losses which were Incurred at most 60 days prior to the effective date of this Agreement Losses for subsequent Agreement Periods must have been Incurred on or after the effective date F16529 over (1 87) NO *7 AN ORDINANCE ACCEPTING THE PROPOSAL OF WASHINGTON NATIONAL INSURANCE COMPANY FOR EXCESS INSURANCE FOR THE CITY'S HEALTH INSURANCE PLAN AND FOR LIFE INSURANCE FOR CITY EMPLOYEES, AUTHORIZING THE EXPENDITURE OF FUNDS THEREFOR, AND PROVIDING AN EFFECTIVE DATE WHEREAS, the City has advertised and accepted proposals for life insurance coverage for its employees and for excess insurance for its health insurance program for City employees, and WHEREAS, the City Manager having recommended to the City Council that the proposal of Washington National for said insurance coverages be accepted as being the lowest and best proposal received by the City, NOW, THEREFORE, THE COUNCIL OF THE CITY OF DENTON HEREBY ORDAINS SECTION I That the City hereby accepts the proposal of Washington—Iational Insurance Company for excess stop loss insurance for the City's employee health insurance and for life insurance for its employees, a copy of which proposal is attached hereto and incorporated by reference herein SECTION II That the expenditure of funds for such insurance coverages is hereby authorized SECTION III. That this ordinance shall become effective imme3i7ieiy upon its passage and approval PASSED AND APPROVED this the day of October, 1987 ATTEST: FETAAY A ROVED AS TO LEGAL FORM DEBRA ADAMI DRAYOVITCH, CITY ATTORNEY Aggregate Deductible shall mean for the Initial Agreement Period the amount determined at the close of the Initial agreement Period by the use of the Aggregate Deductible Formula set forth in Part III of this agreement for a Subsequent Agreement Period the amount determined at the close of that Subsequent Agreement Period by the use of the Aggregate Deductible Formula set forth in Part III or by the use of the revised Aggregate Dedo tible Formula then in effect for that Subsequent Agreement Period D Individual Deductible shall mean $ 60 000 of Individual Loss which must be paid under the Plan in am one Agreement Period for any one covered individual before the Companv will reimburse the Plan Sponsor as set forth in Part II E Indnidual Loss for the Initial Agreement Period shall mean only such amounts actually paid b) the Plan Sponsor in (roh on or after the Effective Date of this Agreement but prior to the beginning of the Subsequent Agreement Pt nod in payment of the benefits specified in the Plan that are paid to one particular person or to her or his assignees in settlement of the claim made by that person Inditiduai Loss for any Subsequent Agreement Period shall mean only such amounts actually paid by the Plan Sponsor in cash on or after the beginning date of that Subsequent Agreement Period and prior to the beginning date of the next Subsequent Agreement Period in payment of the benefits specified in the Plan that are paid to one particular person or to her or his assignees in settlement of the claim made bs that person Aggregate Loss shall mean (1) such amounts actually paid by the Plan Sponsor in cash nn payment of the benefits specified in the Plan to all persons covered under that Plan or to their assignees in settlement of claims made by such persons minus those amounts eligible for reimbutsement under the Individual Stop Loss provision of this agreement and (2) an amount equal to the Individual Loss Premium paid to the Company by the Plan Sponsor Aggregate Loss applicable to the Initial Agreement Period shall be such amounts set forth in (1) above that sit actually paid on or after the Effective Date of this Agreement but prior to the beginning of the next Subsequent Agreement Period and the Individual Loss Premium paid for the Initial Agreement Period Aggregate Loss applicable to each Subsequent Agreement Period shall be such amounts set forth in, (1) above thit are actually paid on or after the beginning date of that Subsequent Agreement Period and prior to the beginning date of the next Subsequent Agreement Period and the Individual Loss Premium paid for that Subsequent Agreement Period G Indnidual Loss or Aggregate Loss shall at no time include extra contractual damages of anv nature compensators damages or any punitive damages assessed against the Plan Sponsor and the Company shall not be liable for any such damages The Plan Sponsor hereby agrees to hold harmless the Company from any such damages assessed against the Plan Sponsor and also agrees that such damages will not be used to satisfy an) Individual Loss Deductible or Aggregate Loss Deductible H Amounts actually paid shall mean the checks or drafts issued for payment of Individual Loss or Aggregate Loss but it shall not mean court cost penalties interest upon judgments or investigation adjustment or legal expense The date of issue of each check or draft shall be considered the date of payment [ Monthly Deductible Information shall mean that information needed to compute the Monthly Deductible amount a, set forth in Part III of this agreement or any revision of Part III which is then in force PART H INDIVIDUAL STOP LOSS AND AGGREGATE STOP LOSS PROVISION The Compan> in consideration of the payment by the Plan Sponsor of the Individual Stop Loss Premium and the Ag^regate Stop Loss Premium required by the Company HEREBY AGREES TO REIMBURSE the Plan Sponsor for A 100 per tent of the amount by which the Individual Loss incurred by the Plan Sponsor in settlement of a claim for any one covered individual exceeds the Individual Deductible amount during a particular Agreement Period subject to an Individual Lifetime Maximum Benefit for any one individual of $1 , 00 0 , 0 00 and B 100 per cent of the amount by which the Aggregate Loss incurred by the Plan Sponsor exceeds the Aggregate Deductible amount during each separate Agreement Period subject to maximum reimbursement of $250,000 per Agreement Period The Company at its own election and expense shall have the right to participate with the Plan Sponsor in the defense or appeal of any action suit or proceeding in which it may in its judgment become involved The Company shall have no obligation to defend the Plan Sponsor in any action arising under the Plan Sponsor s welfare benefit plan Page 2 of b F10979D Washinmon national° INSURANCE COMPANY EVANSTON ILLINOIS 60201 INDIVIDUAL STOP LOSS AND AGGREGATE STOP LOSS AGREEMENT EFFECTIVE DATE October 1, 1987 THE PLAN SPONSOR City of Denton STATE OF DELIVERY Texas INITIAL AGREEMENT PERIOD Beginning on 10/ 1/8% Closing on 10/ 1 /88 SUBSEQUENT AGREEMENT PERIOD Beg inning on 10/ 1 /88 and Closing on 9/30/89 of each vear thereafter during the continuance of this agreement AGGREGATE STOP LOSS PREMIUM $ 9 075 Payable on10/1/8% and Annually on 10/1 is amended to revise the premium of each year thereafter until this Agreement INDIVIDUAL STOP LOSS PREMIUM (See Part IV) Since the Plan Sponsor has established a welfare benefit plan for payment of certain hospital surgical medical and related expense on behalf of all persons for whom contributing employers accepted by the Plan Sponsor for coverage under thi, Plan are required to makc contribution to the City of Denton and all such persons eligible dependents and Since the Plan Sponsor is desirous of limiting that portion of their liability under this welfare benefit plan which exceeds the Aggregate Deductible amount and the Individual Deductible Amount and Since Washington National Insurance Company is willing to reimburse the Plan Sponsor for a certain portion of that liability The Plan Sponsor and Washington National mutually agree to the following terms and conditions PART I DEFINITIONS Where the following words and phrases appear in this agreement they shall have the respective meaning set forth below unless their context clearly indicates to the contrary A The Company shall mean Washington National Insurance Company B Plan shall mean the welfare benefit plan of the Plan Sponsor a copy of this Plan is attached and labeled Article A and is hereby made a part of this agreement F10979D Page Iof6 PART IV THE INDIVIDUAL STOP LOSS PREMIUM The rates used to compute the first monthly Individual Stop Loss Premium for the Initial Agreement Period are set forth below These rates shall apply until the end of the Initial Agreement Period unless changed by agreement between the Plan Sponsor and the Company during the Agreement Period as a result of a change in the Plan For Subsequent Agreement Periods the rates used to compute each monthly Individual Stop I oss Premium shall be those mutually agreed upon by the Plan Sponsor and the Compfny A Premium Rate Covered Person Unit Monthly Premium Rate Employees Dependents $3 29 $3 39 To compute the monthly Individual Stop Loss Premium the number of Covered Person Units covered under the Plan on the first day of that month in each category shown above must be multiplied by the Monthly Premium Rate shown opposite the category The monthly Individual Stop Loss Premium shall be this product on the sum of these products depending on whether there is one or more than one category shown PART V CONTINUATION AND TERMINATION This Agreement will continue in force during the Initial Agreement Period and during each Subsequent Agreement Period subject to the Plan Sponsors payment of premium at such rates as may be required by the Companv and subject to termination as provided In Part VI or as set forth below This Agreemen� shall terminate immediately upon the occurrence of the first of the following (a) mutual consent of the Plan Sponsor and the Company (b) discontinuance of the Plan by the Plan Sponsor (c) any attempt by the Plan Sponsor to amend the Plan, without the prior written approval of the Company (d) adjudication of bankruptcy or insolvency of the Plan Sponsor or (e),upon nonpayment of any premium when due This Agreement may also be terminated by written notice of either party to stile other by registered mail but not less than thirty one days in advance of the termination date set out in such written notice PART VI YEARLY ADDENDUM Within thirty days after the Company s receipt of all Aggregate Loss data for the preceding Agreement Period the Company will issue and deliver to the Plan Sponsor an Addendum to this Agreement setting forth the Aggregate Stop Loss Premium the Monthly Deductible rectors, and the minimum Aggregate Deductible for the current Agreement Period This Addendum shall be sighedlin duplicate by the Plan Sponsor and an executed copy returned to the Company In the event the Plan Sponsor should refuse to accept such Addendum for this Agreement Period and fail to execute and deliver the said Addendum and any additional Aggregate Stop Loss Premium due to the Company by the thirtieth day after the date the Addendum is mailed to the Plan Sponsor, this entire Agreement will be deemed to have terminated at the close of the preceding Agreement Period, and the Company shall thereupon refund the Aggregate Stop Loss Premium paid for this Agreement Period, and shall if the Individual Stop Loss Premium is greater also refund the difference between (a) the Individual Sto Loss Premium paid by the Plan Sponsor during this Agreement Period and (b) the amount paid by the Companv undr the Individual Stop Loss Provision, Part II A in reimbursement of specified Individual Loss incurred by the Plan Sponsor uring this Agreement Period In the event of such deemed termination, the Plan Sponsor hereby agrees that if (b) above exceeds (a) above the Plan Sponsor shall refund to the Company an amount equal to the excess of (heir reimbursement after the premium PART VII PLAN CHANGES The Plan Sponsor shall promptly furnish the Company with all proposed Plan amendments endorsements, or riders If any change in Plan if effected shall in the opinion of the Company increase the risk assumed by the Company the Company shall have the option of notifying the Plan Sponsor of (a) all increase in the Monthly Deductible factors and the minimum Aggregate Claim Deductible to be effective for the Agreement Period in which such change becomes effective and ( in a se In the Indiidual Agreement Period t which suremium Rate and ch change becomes a Individual Stop Loss Deductible to be effective for the remainder F10979D Page I of b With regard to the Aggregate Stop Loss the Company shall have no obligation to make pay ment to the Plan Sponsor until the thirtieth day following the Plan Sponsor s submission to the Company of all Aggregate Loss data and all Monthly Deductible Information for a particular Agreement Period With regard to the Individual Stop Loss the Lonnpan% shall have no obligation to make payment to the Plan Sponsor until the thirtieth day following the Plan Sponsor s submission to the Company of any data regarding an Individual Loss which has eviceeded the Indnidual Deductible PART III THE AGGREGATE DEDUCTIBLE FORMULA The formula for and the factors used to compute the Aggregate Deductible for the Initial Agreement Period are established as of the Effective Date of this agreement The formula for and the factors used to compute the Aggregate Deductible for any Subsequent Agreement Period shall be established as described In Section D below of this Part The Aggregate Claim Deductible shall he determined at the end of the Agreement Period by use of the following formula method and factors unless revised as set forth in Section D below of this Part A Dlonthly Deductible Factor Covered Person Unit Monthly Deductible Factor Employee $106 88 Spouse $ 99 12 Child(ren) $ 62 70 Family $136 99 B Starting with the first month of the Agreement Period the number of Covered Person Units covered under the Plan on the first day of that month in each category shown above will be multiplied b} the factor shown opposite the category The Monthly Deductible amount shall be this product or the sum of these products depending on whether there is one or more than one category shown except that (I ) in the event of a strike lockout or work stoppage caused by any disagreement between an employer and all or certain persons covered under the Plan the number of Covered Person Units used to compute the Monthly Deductible Amount in the month immediately piecedmg such strike lockout or work stoppage will be used to determine the nIonthly Deductible Amount for the month or months during which the strike lockout or work stoppage exists (2) in the event of a reduction of Covered Person Units regardless of the reason the Monthly Deductible amount shall reduce no more than 5vo from the month immediately preceding the one in which the reduction occurs and no more than 50e additionally each month thereafter during the continuance of the reduction C The sum of the first twelve Monthly Deductible amounts will be the Aggregate Deductible except that regardless of such actual total the minimum Aggregate Deductible amount shall not be less than 90% of the first Monthly Deductible amount multiplied by twelve D The above Monthly Deductible Factors and the minimum Aggregate Deductible shall apply until the end of the Initial Agreement Period unless changed by agreement between the Plan Sponsor and the Company during the Agreement Period as a result of a change in the Plan For Subsequent Agreement Periods the Monthly Deductible Factor and the minimum Aggregate Deductible will be determined by mutual agreement of the Plan Sponsor and the Company and set forth in an Addendum to this Agreement signed by the parties hereto E If this Stop Loss Agreement should terminate oil any date other than the closing date of the Initial Agreement Period or of any Subsequent Agreement Period there will be no pro ration of the minimum Aggregate Deductible Oil the contrary the entire minimum Aggregate Deductible or the total of Monthly Deductible amounts determined for such partial Agreement Period whichever is greater will be applied to determine the Company's liability for any partial Agreement Period F10979D Page 3 of 6 PART XIV PARTIES TO AGREEMENT ll not This ever between the Compatween the ny and any covered thean Sponsor and Company or beneficiary unand this der he Plan ment aSponsor create Welfare right or legal XV OVERSIGHTS 0 it is understood and agreed that if failure to comply with any terms of this Agreement is shown to be unintentional and the he positions they would have occupied had not m result of misunderstanding or oversight on the part of either the a misunderstanding oroveniCompany both parties shall be restored to ght occurred XVI ARBITRATION All disputes between the parties to this Agreement upon which an amicable understanding cannot be reached may be decided by arbitration The Court of Arbitrators, which Is to be held in the city where the Home Office of the Plan Sponsor fiidled shall Plan consist of three arbitrators familiar with employee benefit plans One of the arbitrators shall be appointed Sponsor, one by the Company and the third shall be selected by the first two appointees prior to the beginning of the arbitration ice of a rd the ppointment shall be ft to the idnt or any Vice (President of theaAmerrican Arbitratiunable to oneAss ciationupon the hoThe arbitraitors are aemp empowered to decideeall questions sofIssues and shall be es of uity and free ce Industry rather than by strict application of aldrules lof evidence nd awuTi They shall practicesry ft shaldecide bya he insurance and reinsurance majority of votes and the a will be no by he losinof g party al from he arbitrators decisionall The cost o arbitration including the fees of the arbitrators rne IN WITNESS WIIEREOF the Plan executed and delivered on the dates sse hown below thensor and Company and supersedinglall prior aggreeve ments caused this Agreement to be _ City of Denton (I luein called the Plan Sponsor) By Title Date lio Title Date 13N I ItIL _ Date Washington National Insurance Company (Herein called the Company) By i Titl�" 1�Daf By Title Date — BY Title Date BY Title Date F1n979D Page 6 of 6 PART XIV PARTIES TO AGREEMENT This Agreement is only between the Plan Sponsor and the Company and this Agreement shall not create any right or legal relation whatever between the Company and any covered person or beneficiary under the Plan Sponsors Welfare Plop XV OVERSIGHTS It is understood and agreed that if failure to comply with any terms of this Agreement Is shown to be unintentional and the result of misunderstanding or oversight on the part of either the Plan Sponsor or Company both parties shall be restored to the positions they would have occupied had not misunderstanding or oversight occurred XV► ARBITRATION All disputes between the parties to this Agreement upon which an amicable understanding cannot be reached may be decided by arbitration Che Court of Arbitrators which is to be held in the city where the Home Office of the Plan Sponsor is domiciled shall consist of three arbitrators familiar with employee benefit plans One of the arbitrators shall be appointed by the Plan Sponsor one by the Company and the third shall be selected by the first two appointees prior to the beginning of the arbitration Should the two arbitrators be unable to agree upon the choice of a third the appointment shall be left to the President or any Vice President of the American Arbitration Association The arbitrators are empowered to decide all questions or issues and shall be free to reach their decision by application of principles of equity and customary practices of the insurance and remburance Industry rather than by strict application of all rules of evidence and law They shall decide by a majority of votes and there will be no right of appeal from their written decision The cost of arbitration including the fees of the arbitrators shall be borne by the losing party unless the arbitrators shall decide otherwise IN WITNESS WHEREOF the Plan Sponsor and the Company have by their respective officers caused this Agreement to be executed and delivered on the dates shown below replacing and superseding all prior agreements City of Denton _ (Ilcrein called the Plan Sponsor) By Tine �_ev-� /iC Da4 Zo _ 23—f7 B� Title Date liv Title Date 13s l itic Date By Title Date MI Title Date By Title Date By Title Date Washington National Insurance Company (Herein called the Company) F10()79D Page 6 of 6 STOP -LOSS COVERAGE QUOTATION FOR: INDIVIDUAL AND AGGREGATE STOP -LOSS COVER1kGE PLANSPONSOR City of Denton LOCATION Denton Texas EFFECTIVE DATE 10/ 1 /87 NUMBER OF COVERED PERSONS LOSSES ELIGIBLE FOR REIMBURSEMENT ❑ I&P 12/12 ❑ I&P 12/15 ❑ DSR 12112 INDIVIDUAL STOP LOSS Employees 424 Dependent Unite - ❑ DSR 12/16 ® PAID ❑ Medical ❑ 60,000 Individual Deductible (Per Agreement Period) Individjual Maximum Benefit 1 $ j and, nnn Percentage of Reimbursement for Claims in Excess of the Individual Ded ctible 100 % AGGREGATE STOP LOSS $ 106.88 Per Employee Unit ❑ Medical ❑ Dental Per Spouse Unit $ 99 12 Monthly Deductible Factor Per Child Unit $ 62-70 Per Family Unit = 116-QQ Estimated Aggregate Deductible (Annual) $ 845,000 Estimated Minimum Aggregate Deductible (Annual) $ 760,500 M um Reimbursement Udder the Agreement 250,000 Per Agreement Period S Percentage of Reimburaement for Claims in Excess of the Aggregate Deductible 100 % PREMIUM Aggregate Stop -Lose Premium PPayable Annually in Advance) Individual Stop -Loss Premium) Monthly Rate per Covered Peron (Payable Monthly in Advance) Employees 8. 3-29 Dependent@ 8 3.39 Estimated Annual Individual Stop -Lose Premium Estimated Total Annual Stop•Loss Premium 25.201 F j lfn :» F 155254 WSSh111gtOr1 national a 18 86) IN RLNCC COMMNV Washington national• INSUVNCE COMPANY October 6, 1987 Ms Nedra White Insurance Dept City of Denton 324 E McKinney Denton, TX 76201 Dear Nedra JOHN S BREW ON Regional Group Manager ROBERT M DICKSON Regional Account Executive ROSA BYERS Group Service Representative LARRY A FALDET Associate Group Manager TIMOTHY P HENRIKSEN Group Sales Representative DEREK S MARSH Group Representative Park Central It - Suite 520 7540 LBJ Freeway Dallas Texas 75251 2141233 9894 Attached is a completed master application for group life and AD&D along with a suppliment to the application which covers mental illness Also attached is a new replacement page describing the group life and AD&D Rest assured that Washington National will service your employees in a manner which will warrant your continued confidence Si ce sly yours, �S Brewton gional Group Manager Evanston, Illinois 002M 8 A Wlwhington National Corporation Flnaneld Stervios Company schedule of benefits and/or cost LIFE AND AD&D INSURANCE CLASS All Employees RATES CLASS All Employees AMOUNT Amount of coverage one time annual one time annual earning rounded to the next highest$1,000 PREMIUM FOR LIFE AND AD&D $ 27 per $1,000 Life & AD&D coverage is in compliance with the new ADEA laws and coverge is as follows Active Employees under age 70 Reduction to 65% at age 70 Reduction to 45% at age 75 Reduction to 30% at age 80 1x Annual Earnings City of Denton October 6, 1987 Washington F se3 national �am (aa INWRANCCCOMMNY MASTER APPLICATION FOR GROUP INSURANCE made to WASHINGTON NATIONAL INSURANCE COMPANY, EVANSTON, ILLINOIS 60201 Full Legal Name of Proposed Policyholder Legal Street Addrees. 324 McKinney City Denton State, Texas Zip Code 76201 Authorized Repmmntatl"/Tft Nature of Business or Organization City Employees Polloyholder Contribution Employee Premium - Life 100 % Health % Dependent Premium - Life % Health % Wafting Period Is. ❑ Ut of Month After of Employment ❑ lot of Month After Date of Employment ❑ other Waiting Period ❑ IS ❑ IS NOT applicable on policy effectlw date INDICATE BELOW ALL OF THE COVERAGES FOR WHICH APPLICATION 18 MADE M Life Insurance ❑ Basic Medical with ❑ Dental Expense supplemental Major Medical ® Accidental Death, Dismemberment (3 Comprehenalw Major Medical ❑ Vision Care ❑ Dependent Life ❑ ❑ Prescription Drug ❑ Disability Income ❑ ❑ DESCRIPTION OF ELIGIBLE CLASSIFICATION$ AND BENEFIT LEVELS ARE DETAILED ON THE SCHEDULE OF BENEFITS PAGE CONTAINED IN THE WASNINGTON NATIONAL PROPOSAL DATED The proposed efteotho date requested for this group Insurance In 11 / 1 /87 The sum of 1 has been tendered as a deposit to be applied toward premium due I UNDERSTAND THAT THE POLICYPES) WILL NOT BECOME EFFECTIVE UNLESS AND UNTIL WASHINGTON NATIONAL�INSURANCE COMPANY'S HOME OFFICE APPROVES THIS APPLICATION Signed at this day of 19 — Signature of Witness Authorized Representative SUP1 -i1 IENT TO MASTER APYL_ JATION WASHINGTON NATIONAL INSURANCE COMPANY State law requires that the Company offer each Policyholder certain coveragels) which the Policyholder may either accept or reject A Policyholder who accepts this coverage must complete and sign section I of this form A Policyholder who rejects it must sign section II I In consideration of the additional premium required if any I request that the Company add the optional coverage(s) listed below to my new or revised group health policy ❑ Mental Illness This additional coverage shall become effective on 1 the date the policy is effective if it is a new policy or 2 the date of the revision which caused this optional coverage to be offered if the policy is being revised Date Signature of Policyholder II I do not want the additional optional coverage(s) offered above Date Signature of Policyholder If this coverage is being offered because this is a new Policyholder this form shall be attached to and made a part of the Master Application and submitted with the Master Application If this coverage is being offered because an existing policy is being revised this form shall be considered a supplement to the original Master Application the Policyholder has already submitted F15767 (9 86) TX schedule of benefits and/or cost LIFE AND AD&D INSURANCE CLASS AMOUNT All Employees Amount of coverage one time annual one time annual earning rounded to the next highest$1,000 RATES CLASS PREMIUM FOR LIFE AND AD&D All Employees $ 21 per $1,000 Life & AD&D coverage is in compliance with the new ADEA laws and coverge is as follows Active Employees under age 70 Reduction to 65% at age 70 Reduction to 45% at age 75 Reduction to 30% at age 80 1x Annual Earnings City of Denton October 6, 1987 Washington F 16M nat `ones • (0-4 MASTER APPLICATION FOR GROUP INSURANCE made to WASHINGTON NATIONAL INSURANCE COMPANY, EVANSTON, ILLINOIS 80201 v Full Loyal Name of Proposed Policyholder- City of nantnn Legal Street Address, 324 McKinney City Denton Stow Texas Zip Code '620.1 Authorised RepresentatlwRltle, Nature of Business or Organisation City Employees Policyholder Contribution Employee Premium - Life 100 % Health % Dependent Premium - Life % Health % Waiting Period Is. ❑ 1at of Month After of Employment ❑ 1st of Month After Data of Employment ❑ Other Waiting Period ❑ IS ❑ IS NOT applicable on policy eHecthre date INDICATE BELOW ALL OF THE COVERAGES FOR WHICH APPLICATION 18 MADE m Life Insurance ❑ Bask Medical with ❑ Dental Expense Supplemental Major Medical ® Accidents[ Death, Dismemberment ❑ Comprehenshre Major Medical ❑ Vision Care ❑ Dependent Life ❑ ❑ Prescription Drug ❑ Disability Income ❑ ❑ DESCRIPTION OF ELIGIBLE CLASSIFICATION$ AND BENEFIT LEVELS ARE DETAILED ON THE SCHEDULE OF BENEFITS, PAGE CONTAINED IN THE WASHINGTON NATIONAL PROPOSAL DATED The proposed effeogve date requested for this group Insurance Is 11 / 1 /87 The sum of 1 has bean tendered as a deposit to be applied toward premium due I UNDERSTAND THAT THE POLICY(IRS) WILL NOT BECOME EFFECTIVE UNLESS AND UNTIL WASHINGTON NATIONAL INSURANCE COMPANY'S HOME OFFICE APPROVE$ THIS APPLICATION Signed at this day of 19 _ Signature of Witness Authorisod Represantathe Wi : LAMENT TO MASTER APPLICATION WASHINGTON NATIONAL INSURANCE COMPANY State law requires that the Company offer each Policyholder certain coveragels) which the Policyholder may either accept or reject A Policyholder who accepts this coverage must complete and sign section I of this form A Policyholder who rejects it must sign section II I In consideration of the additional premium required if any I request that the Company add the optional coveragelsl hated below to my new or revised group health policy ❑ Mental Illness This additional coverage shall become effective on 1 the date the policy is effective if it is a new policy or 2 the date of the revision which caused this optional coverage to be offered if the policy is being revised Date Signature of Policyholder II I do not want the additional optional coverage(s) offered above Date Signature of Policyholder If this coverage is being offered because this is a new Policyholder this form shall be attached to and made a part of the Master Application and submitted with the Master Application If this coverage is being offered because an existing policy is being revised this form shall be considered a supplement to the original Master Application the Policyholder has already submitted F15767 (9 86) TX F E� Wast7fnMon nationar INSURANCE COMPANY EVANSTON ILLINOIS 6M01 FEB 2 21988 INDIVIDUAL STOP -LOSS AND AGGREGATE STOP -LOSS AGREEMENT EFFECTIVE DATE November 1, 1987 THE PLAN SPONSOR City of Denton STATE OF DELIVERY Texas INITIAL AGREEMENT PERIOD Beginning on November31 1987 1988 Closing on October SUBSEQUENT AGREEMENT PERIOD Beginning on November 1 and Closing on October 31 of each year thereafter during the continuance of this Agreement AGGREGATE STOP LOSS PREMIUM The amount shown on the Addendum under PREMIUMS will be payableon November 1, 1987 andAnnuallyon November 1 of each year thereafter until this Agreement is amended to revise the premium STOP LOSS PREMIUM (See Part IV) Since the Plan Sponsor has established a welfare benefit plan for payment of certain eligible expenses on behalf of all persons for whom contributing employers, accepted by the Plan Sponsor for coverage under this Plan, are required to make contributions to the "Plan ponsorls Welfare Benefit Plan" and all such persons'ehgibledependents, and Since the Plan) Sponsor is desirous of limiting that portion of their liability under this welfare benefit plan which exceeds Ithe Aggregate Deductible amount and the Individual Deductible Amount and Since Washington National Insurance Company is willing to reimburse the Plan Sponsor for a certain portion of that habilit The Plan Sponsor and Washington National mutually agree to the following terms and conditions PART DEFINITIONS Where the following words and phrases appear in this Agreement, they shall have the respective meaning set forth below unless their context clearly indicates to the contrary A Company shall mean Washington National Insurance Company B Plan shall mean the welfare benefit plan of the Plan Sponsor, a copy of this Plan is attached and labeled Article A and is hereby made a part of this Agreement The pr visions of Article A (or Temporary Article A if a formal Plan Document is unavailable) that are pei tment to determine which individuals are to be covered under the Plan, the tune period they will be covered under the Plan and the benefits for which they are covered under the Plan will be considered pertinent to this Stop Loss Agreement The Plan Sponsor agrees that (A) all liabilities creattee4 by Article A (or temporary Article A if a formal Plan Document is unavailable) belong only to the Plan Sponsor, and (B) Washington National s liability shall be limited to the reimbursement . . . .. _ _e ..t__ ♦ ___.v__a F 0 F16526 I Page 1 of 7 C Aggregate Deductible shall mean for the Initial Agreement Period the amount determined at the close of the Initial Agreement Period by the use of the Aggregate Deductible Formula set forth in Part III of this Agreement for a Subsequent Agreement Period, the amount determined at the close of that Subsequent Agreement Period by the use of the Aggregate Deductible Formula set forth in Part III or by the use of the revised Aggregate Deductible Formula then in effect for that Subsequent Agreement Period D Individual Deductible shall mean the amount of Individual Loss shown as the Deductible on the Addendum under Individual Stop Loss Specifications winch must be paid under the Plan in any one Agreement Period for any one covered individual before the Company will reimburse the Plan Sponsor as set forth in Part II E Individual Loss for each Agreement Period shall mean only such amounts which were incurred by any one person covered under the Plan and actually paid by the Plan Sponsor in cash within the period of time indicated in the Addendum under Losses Eligible for Reimbursement in payment of the benefits specified in the Plan that are paid to one particular person, or to his or her assignees in settlement of the claim made by that person Amounts are considered to be incurred on those days the service(s) or the supply(ies) are provided If included under this Agreement, Disability In come Benefit amounts are considered to be incurred during the days a Disability Income Benefit is payable under the Plan In no event shall Individual Loss include amounts paid after the termination of the Agreement F Aggregate Loss for each Agreement Period shall mean (1) such amounts which were incurred by all persons covered under the Plan and actually paid by the Plan Sponsor in cash within the period of time indicated in the Addendum under Losses Eligible for Reimbursement in payment of the benefits specified in the Plan to all persons covered under the Plan or to their assignees in settle ment of claims made by such persons, (2) minus those amounts eligible for reimbursement under the Individual Stop Loss provision of this Agreement and (3) plus an amount equal to the Individ ual Stop Loss Premium payable to the Company by the Plan Sponsor Amounts are considered to be incurred on those days the service(s) or the supphes(ies) are pro vided If included under this Agreement Disability Income amounts are considered to be incurred during the days Disability Income is payable under the Plan In no event shall Aggregate Loss in clude amounts paid after the termination of the Agreement G Individual Loss or Aggregate Loss shall at no time include extra contractual damages of any nature compensatory damages or any punitive damages assessed against the Plan Sponsor and the Company shall not be liable for any such damages The Plan Sponsor hereby agrees to hold harmless the Company from any such damages assessed against the Plan Sponsor and also agrees that such damages will not be used to satisfy any Individual Loss Deductible or Aggregate Loss Deductible H Amounts actually paid shall mean the checks or drafts issued for payment of Individual Loss or Aggregate Loss and honored but it shall not mean court cost penalties, interest upon judgments or investigation expense adjustment expense or legal expense The date of issue of each check or draft shall be considered the date of payment I Monthly Deductible Information shall mean that information needed to compute the Monthly De ductible amount asset forth in Part III of this Agreement or any revision of Part III winch is then in force PART II INDIVIDUAL STOP LOSS AND AGGREGATE STOP LOSS PROVISION The Company in consideration of the payment by the Plan Sponsor of the Individual Stop Loss Premium and the Aggregate Stop Loss Prermum required by the Company HEREBY AGREES TO REIMBURSE the Plan Sponsor for A The percent shown on the Addendum under the Individual Stop Loss Specifications of the amount by which the Individual Loss incurred by the Plan Sponsor in settlement of a claim for any one covered individual exceeds the Individual Deductible amount during a particular Agree ment Period subject to an Individual Maximum Benefit for any one individual of the amount shown on the Addendum under the Individual Stop Loss Specifications, and B The percent shown on the Addendum under the Aggregate Stop Loss Specifications of the amount by winch the Aggregate Loss incurred by the Plan Sponsor exceeds the Aggregate De ductible amount during each separate Agreement Period, subject to the maximum reimbursement as shown on the Addendum under the Aggregate Stop Loss Specifications F16528 Page 2 of 7 The Company, at its own election and expense, shall have the right to participate with the Plan Sponsor in the defense or appeal of any action, suit, or proceeding in winch it may, in its judgment, become involved The Company shall have no obligation to defend the Plan Sponsor in any action arising under the Plan Sponsor s welfare benefit plan With regard to the AGGREGATE STOP LOSS the Company shall have no obligation to make payment to the Plan Sponsor until the thirtieth day following the Plan Sponsor s submission of a claim to the Company containing all necessary Aggregate Loss data and all Monthly Deductible Information for a particular Agreement Period With regard to the INDIVIDUAL STOP LOSS, the Company shall have no obligation to make payment to the Plan Sponsor until the thirtieth day following the Plan Sponsor's submission of a claim to the Company containing any necessary data regarding an Individual Loss which has exceeded the Individual Deductible If the Addendum indicates Actively at Work is required then Individual Loss or Aggregate Loss as used herem, will not include amounts of loss incurred by any person covered under the Plan or loss paid for by the Plan Sponsor unless the covered person was actively at work on the later of 1 The effective date of this Agreement or 2 The first day the individual is eligible for coverage under the Plan For a covered person not actively at work on the later of these two dates, only those losses which were incurred by such person on or after the date the covered person is again actively at work will be included under the meaning of Individual Loss or Aggregate Loss An employee is actively at work if he or she is working full time at Ins or her regular lob or if the date in question is not a day when the employee is required to work then the employee must be able to work full time at the regular place of employment A dependent or a retired person is actively at work if on the date in question he or she is not hospital confined for at least one day immediately prior to that date and is able to perform his or her normal duties and activities PART III THE AGGREGATE DEDUCTIBLE FORMULA The formula foriand the factors used to compute the AGGREGATE DEDUCTIBLE for the Initial Agree- ment Period are established as of the Effective Date of this Agreement The formula for and the factors used to compute the AGGREGATE DEDUCTIBLE for any Subsequent Agreement Period shall be established as described in Section C below of this Part The AGGREGATE DEDUCTIBLE shall be determined at the end of the Agreement Period by use of the following formula method and factors unless revised as set forth in Section C below of this Part The factors are shown on the Addendum under MONTHLY DEDUCTIBLE FACTORS They include the COVERED BENEFIT COVERED PERSON UNIT and the MONTHLY DEDUCTIBLE FACTOR A Starting with the first month of the Agreement Period the number of COVERED PERSON UNITS covered under the Plan on the first day of that month in each category shown on the Addendum will be multiplied by the factor shown opposite the category The Monthly Deductible amount shall be this product or the sum of these products depending on whether there is one or more than one category shown except that (1) in the event of a strike, lockout, or work stoppage caused by any disagreement between an employer and all or certain persons covered under the Plan the number of COVERED PERSON UNITS used to compute the Monthly Deductible Amount in the month immediately preceding such strike, lockout, or work stoppage will be used to determine the Monthly Deductible amount for the month or months during which the strike, lockout or work stoppage exists (2) in the event of a reduction of COVERED PERSON UNITS, regardless of the reason the Monthly Deductible amount shall reduce no more than 6% from the month immediately preceding the one in winch the reduction occurs and no more than 6 % additionally each month thereafter during the continuance of the reduction F16526 Page 3 of 7 B The sum of the first twelve Monthly Deductible amounts will be the AGGREGATE DEDUCT IBLE except that regardless of such actual total, the minimum AGGREGATE DEDUCTIBLE amount shall not be less than 90% of the first Monthly Deductible amount multiplied by twelve C The MONTHLY DEDUCTIBLE FACTORS and the nummum AGGREGATE DEDUCTIBLE shall apply until the end of the Initial Agreement Period unless changed by agreement between the Plan Sponsor and the Company during the Agreement Period as a result of a change in the Plan For Subsequent Agreement Periods the MONTHLY DEDUCTIBLE FACTOR and the mimmum AGGREGATE DEDUCTIBLE will be determined by mutual agreement between the Plan Sponsor and the Company and set forth in an Addendum to this Agreement signed by the parties hereto D If this Stop Loss Agreement should terminate on any date other than the closing date of the Initial Agreement Period or of any Subsequent Agreement Period there will be no pro ration of the nummum AGGREGATE DEDUCTIBLE On the contrary, the enure minimum AGGRE GATE DEDUCTIBLE or the total of Monthly Deductible amounts determined for such partial Agreement Period whichever is greater will be applied to determine the Company's liability for any partial Agreement Period PART IV THE INDIVIDUAL STOP LOSS PREMIUM The rates used to compute the first monthly Individual Stop Loss Premium for the Initial Agreement Period are set forth on the Addendum These rates shall apply until the end of the Initial Agreement Period, unless changed by mutual agreement between the Plan Sponsor and the Company during the Agreement Period as a result of a change in the Plan For Subsequent Agreement Periods the rates used to compute each monthly Individual Stop Loss Premium shall be those mutually agreed upon by the Plan Sponsor and the Company The MONTHLY PREMIUM RATE, COVERED PERSON UNIT and COVERED BENEFIT are shown on the Addendum under PREMIUMS To compute the monthly Individual Stop -Loss Premium the number of COVERED PERSON UNITS covered under the Plan on the first day of that month in each category shown on the Addendum must be multiplied by the MONTHLY PREMIUM RATE shown opposite the category The monthly Individual Stop -Loss Premium shall be this product or the sum of these products depending on whether there is one or more than one category shown PART V CONTINUATION AND TERMINATION This Agreement will continue in force during the Initial Agreement Period and during each Subsequent Agreement Period subject to the Plan Sponsor s payment of premium, at such rates as may be required by the Company and subject to termination as provided in Part VI or as set forth below This Agreement shall terminate immediately upon the occurrence of the first of the following (a) mutual consent by the Plan Sponsor and the Company, (b) discontinuance of the Plan by the Plan Sponsor (c) any attempt by the Plan Sponsor to amend the Plan without the prior written approval of the Company, (d) adjudication of bankruptcy or insolvency of the Plan Sponsor (e) upon nonpayment of any premium when due or (f) delegation of the Plan Sponsor's duties under this Agreement to a Third Party AdmunstratorlClaims Administrator which has not been approved by the Company This Agreement may also be terminated by written nonce of either party to the other by registered mail but not less than thirty one days in advance of the termination date set out in such written notice PART VI YEARLY ADDENDUM Within thirty days after the Company s receipt of all the Loss data for the preceding Agreement Period, in the format required by the Company, the Company will issue and deliver to the Plan Sponsor a completed Addendum to this Agreement indicating the terms for the renewal Agreement Period This Addendum shall be signed in duplicate by the Plan Sponsor and an executed copy returned to the Company If the Plan Sponsor should refuse to accept such Addendum for this Agreement Period and fail to execute and deliver the said Addendum and any additional premiums due to the Company by the thirtieth day after the date the Addendum is mailed to the Plan Sponsor this entire Agreement will be deemed to have terminated at the close of the preceding Agreement Period and the Company shall thereupon refund the Premiums paid for this Agreement Period The Plan Sponsor agrees to return any claims amounts reimbursed for this Agreement Period F16626 Page 4 of 7 PART VII PLAN CHANGES The Plan SponyIor shall promptly furnish the Company with all proposed Plan amendments endorsements, or riders If any change in the Plan, if effected, shall, in the opinion of the Company, increase the risk assumed by the Company, the Company shall have the option of notifying the Plan Sponsor of (a) an increase in the MONTHLY DEDUCTIBLE FACTORS and the mimmum Aggregate Claim Deductible to be effective for the Agreement Period in which such change becomes effective and (b) an increase in the Individual Stop -Loss Premium Rate and the Individual Stop Loss Deductible to be effective for the remainder of the Agreement Period in which such change becomes effective Upon the written agreement of the Plan Sponsor to the increases an executed copy of such agreement, endorsement or rider shall be returned to the Company within 30 days of the effective date and shall be made a part of Article A and thereafter be considered as a part of the Plan If written acceptance is not provided to the Company within thirty days of notification from the Company, the change will not be effective as part of this Agreement until the first of the month following the return of the written acceptance If any change in the Plan shall not, in the opinion of the Company, increase the risk assumed by the Company if that change were to become effective the Company shall so notify the Plan Sponsor If the Plan Sponsor sends an executed copy of this amendment, endorsement or rider to the Company for attachment to Article A, the Plan will be deemed so changed as of the effective date shown on such amendment endorsement, or rider PART VIII DUTIES OF THE PLAN SPONSOR The parties agree that the Plan Sponsor shall have the following duties and obligations A The Plan Sponsor shall be responsible for auditing and calculating and paying all claims preparation of periodic reports including but not limited to monthly reports of the number of COVERED PERSON UNITS, by category and shall maintain and make available to the Company, at all times such information as the Company may reasonably require for proof of payment of Individual Loss and Aggregate Loss by the Plan Sponsor B The Plapn Sponsor will maintain a record of any and all amounts paid in excess of payments required by the provisions of the Plan C The Plan Sponsor agrees to pay all claims within thirty days of the time that proofs of claims are adequate to the extent that payment can properly be made Failure of the Plan Sponsor to pay such claims within the time limit (thirty days) shall cause any such claim to be excluded from counting toward the satisfaction of any Individual Deductible or AGGREGATE DEDUCTIBLE amount D The Plan Sponsor agrees to pay proper claims made by persons covered under this Plan and that funds as necessary will be provided for this purpose Failure of the Plan Sponsor to provide funds when needed for such timely payment will cause the Agreement to immediately lapse the Grace Period will be considered satisfied, and the AGGREGATE DEDUCTIBLE and any Individual Deductible will be considered as not satisfied E The Plan Sponsor shall prepare and submit to the Company on a monthly basis a report of the total of all claims paid during such month and a report of the total number of COVERED PERSON UNITS in each category described on the Addendum under the PREMIUM section and the MONTHLY DEDUCTIBLE FACTOR section The Plan Sponsor shall maintain such other records as are reasonably required by the Company and shall furnish them to the Company upon request The parties also agree that the Plan Sponsor may retain a Third Party Admrmstrator/Claims Administrator that has been approved by the Company to perform any or all of the above listed dunes If the Plan Sponsor delegates duties under this Agreement to an approved Third Party Administrator/Claims Administrator the Plan Sponsor shall submit the Agreement between it and the Third Party Administrator/Claims Adrmmstra for to the Company This Third Party Admrmstrator/Claims Administrator shall be retained and compen sated for adm(nistrative and claims paying services by the Plan Sponsor and shall not be considered as the agent of the Company for admimstrative and claims paying services Should the Plan Sponsor desire to change Third Party Administrator/Claims Administrator while this Agreement is in effect the new Thud Party Adrmmstrator/Claims Administrator must be approved by the Company and the Agreement with the new Thud Party Admimstrator/Claims Admrmstrator must be submitted to the Company F16526 Page 5 of 7 PARTIX TAXES The Company shall be held harmless by the Plan Sponsor from any state premium taxes which the Company may mcur with respect to claims paid (as distinct from the premiums paid to the Company by the Plan Sponsor) under the Plan Sponsor s Plan and the Plan Sponsor shall reimburse the Company annually for such tax expense, if any, as determined by the Company PART X PAYMENT OF PREMIUMS The Plan Sponsor shall remit all premiums as required by the Company to the Company at its Home Office in Evanston Illinois Except as otherwise provided under the Section entitled 'Grace Period,' this Agreement shall automatically terminate if any premium is not paid when due PART XI GRACE PERIOD A grace period of thirty one (31) days without interest charge is allowed for the payment of every premium after the first PART XII DATA The Plan Sponsor shall maintain such records as are reasonably required by the Company and shall furmsh to the Company all pertinent data with respect to persons covered under the Plan The Company shall have the right to inspect the records of the Plan Sponsor at reasonable intervals during business hours for any purpose relating to this Agreement PART XIII MODIFICATION Upon written request by the Plan Sponsor and with the consent of the Company this Agreement may be modified in writing without notice to or consent by any persons covered under this Plan Only the President, a Vice President, or the Secretary of the Company is authorized to modify this Agreement No other person has the authority to change this Agreement or to waive any of its provisions PART XIV PARTIES TO AGREEMENT This Agreement is only between the Plan Sponsor and the Company and this Agreement shall not create any right or legal relation whatever between the Company and any covered person or beneficiary under the Plan Sponsor's Welfare Plan PART XV OVER REIMBURSEMENT The Plan Sponsor agrees that should the Company over reimburse Aggregate Losses due either to clerical error or lack of information on Individual Loss(es) such over reimbursement will be credited towards any re- imbursements due to Individual Loss(es) The Plan Sponsor further agrees that should such over reimburse- ment exceed any reimbursements due to Individual Loss(es), this excess will be refunded to the Company PART XVI ARBITRATION All disputes between the parties to this Agreement upon which an anucable understanding cannot be reached may be decided by arbitration The Court of Arbitrators which is to be held in the city where the Home Office of the Plan Sponsor is domiciled, shall consist of three arbitrators famihar with employee benefit plane One of the arbitrators shall be appointed by the Plan Sponsor one by the Company and the third shall be selected by the first two appointees prior to the beginning of the arbitration Should the two arbitrators be unable to agree upon the choice of a third the appointment shall be left to the President or any Vice President of the American Arbitration Association The arbitrators are empowered to decide all questions or issues and shall be free to reach their decision by application of principles of equity and customary practices of the insurance and reinsurance industry rather than by strict application of all rules of evidence and law They shall decide by a majority of votes and there will be no right of appeal from their written decision The cost of arbitration, including the fees of the arbitrators shall be borne by the losing party unless the arbitrators shall decide otherwise F16626 Page 6 of 7 IN WITNESS WHEREOF, the Plan Sponsor and the Company have by their respective officers caused this Agreement to be executed and delivered on the dates shown below replacing and superseding all Prior agreements Title Date City of Denton Mersin called the Plan Sponsor) fin / 4(' —/ Washington National Insurance Company alled the Company) By Title Senior Vice President Date January 19, 1988 Page 7 of 7 F16526 INDIVIDUAL STOP -LOSS AND AGGREGATE STOP -LOSS ADDENDUM 1 PLAN SPONSOR Full Legal Name • City of Denton Street Address 324 E McKinne City state and Zip Code Denton, Texas 76201 2 AGREEMENT EFFECTIVE DATE 11-1-87 3 Aggregate Stop Loss Specifications Mimmum Deductible '$ 760,500 Percent 100 % 4 Individual Stop Loss Specifications Deductible $ 60,000 Percent 100 % 5 COVERED BENEFITS a INDIVIDUAL STOP LOSS Medical 6 LOSSES ELIGIBLE FOR REIMBURSEMENT ADDENDUM EFFECTIVE DATE 11-1-87 Maximum Reimbursement$ 1.000.000 Maximum Benefit $ 250,000 b AGGREGATE STOP LOSS ® Medical ❑ Dental ❑ Vision ❑ RX/Drugs ❑ Disability Income a ❑ I&P 12/12 which means the Losses were Incurred and Paid witlun the Agreement period for the Initial Agreement Period For subsequent Agreement Periods, Paid within the Agreement Period and Incurred on or after effective date of the Agreement Actively at work is required b ❑ I&P 12115 which means the Losses were Incurred within each Agreement Period and Paid within that Agreement Period plus the 8 months following the end of that Agreement Period Actively at work is required c ❑ DSR 12/12 which means the Losses were Incurred and Paid within the Agreement Period for the Initial Agreement Period For subsequent Agreement Periods, Paid within the Agreement Period and Incurred on or after effective date of the Agreement d ❑ DSR 12/15 which means the Losses were Incurred within each Agreement Period and Paid within that Agreement Period plus the 8 months following the end of that Agreement Period e ® PAID which means the Losses were paid within each Agreement Period Initial Agreement Period includes Losses which were Incurred, at most, 60 days prior to the effective date of this Agreement Losses for subsequent Agreement Periods must have been Incurred on or after the effective date F16529 over (1 87) 7 MONTHLY DEDUCTIBLE FACTORS (USED TO COMPUTE THE AGGREGATE DEDUCTIBLE) COVERED BENEFIT Medical Medical Medical Medical 8 PREMIUMS COVERED PERSON UNIT Employee Spouse Child(ren) Family a Aggregate Stop Lose $ 9,075 (Annual) b Individual Stop -Loss COVERED BENEFIT eFf d c I — Medical COVERED UNIT mph oTee Dependent MONTHLY DEDUCTIBLE FACTOR $106 88 99 12 62 70 136 99 MONTHLY PREMIUM RATE 3 39 9 Agreement Period to which this Addendum is applicable Begins November 1st 19 87 and Ends October 31st 19 88 If the effective date of this Addendum is after the beginning of the Agreement Period this Addendum will replace and supersede any other Addendum for the same Agreement Period for the time period beginning with the effective date of this Addendum and ending with the end of the Agreement Period 10 Full Legal name and address of Third Party Adnumstrator/Claim Administrator Coordinated Benefits Systems 6301 Gaston Ave, Suite 550 104 ❑ None City of Denton PLAN SPONSOR By O��j'to► Signature U �.rl �� I mtie Signed at Date F16529 WASHI N IONALINSURANCE COMPANY By Signature Senior Vice Pre iden �J Title Evanston, IL January 19, 1988 Signed at Date (1 87) AMENDMENT City of 11/1/87 thefolloann The Company and Denton (Plan Sponsor) agree that effective on g will be added to and made part of the Individual Stop Loss Agreement Notwiththe lan onsor payment sof benefit anything d in the n the Plan for purposes of caement for the lculating ng Loss, sha, amounts ll paid ncludethe followingln 1 Benefits covered by any Workers' Compensation or Occupational Disease Law whether or not such policy is in force, 2 Benefits which are not eligible expenses undo the terms of the Plan 3 Benefits paid under the plan which are in excess of usual and customary charges for the locality where administered, 4 Benefits paid under the Plan for any Employee or Dependent whose evidence of good health as a Late Applicant (as defined by Washington National Insurance Company) is not satisfactory to Washington National, 6 Benefits paid for charges or treatment not required because of an accidental injury or illness or not necessary to the care or treatment of such accidental injury or illness, 6 Benefits paid for charges or treatment not recommended and approved by a physician or practitioner whose inclusion in the term "physician" is required by law, f benefits ad been 7 Benefits provisions f he National Association of Insurance Commissioners h mi a onersModel COB Guidelinesd er theas amended from time to time, 8 Benefits paid for losses which are due to war or any act of war whether declared or undeclared, 9 Benefits paid for treatment for cosmetic purposes or for cosmetic surgery Except cosmetic treat ment or surgery due solely to An accidental bodily injury which occurred while the individual was covered under the plan, or b Surgical removal of all or part of the breast tissue as a result of an illness or c Correct a congenital birth defect of an individual who was covered under the Plan on the date of his of her birth usually lives in the same household as 10 Benefits indiividualaor who id for es a member of his or herervices of a person ohimmediate family or the family of his or her spouse 11 peltfor ologexperimental investigational in nature by an proprieechnical assessment body established y any state orFede al government, These 12 Benefits paid for be limited to, deduct blesch s coinsuPlan rance and amoonsor is not unts in xgceted sss ofomaximums would the Plan, but not 13 Benefits paid for a mental or nervous condition or for any substance abuse condition which for any covered Individual exceed the lesser of a The maximum(s) in the Plan, or b $50 000 during any Agreement Period F16627 over (1 87) Except as expressly stated, this Amendment does not waive, alter, or extend any of the other provisions of said Agreement This Amendment expires with the Agreement PI.A'YN SPONSOR a ' Signature Title Signed at F16527 WASHINGTON NATIONAL INSURANCE COMPANY By — &I Signature Senior Vice President 0/- Evanston, IL January 19, 1988 Signed at Date (187) AGREEMENT AMENDMENT The Company and City of Denton (Plan Sponsor) agree that effective on November 1 1987 the items on the attached page(s) which follow, be added to and made a part of the Individual Stop Loss Agreement which was effective on November 1 1487 Except as expressly stated this Amendment does not waive or extend any of the other provisions of said Agreement This Amendment expires with the Agreement City of Denton PLAN SPONSOR By le'!tlff *4n:!- Signature V, /�I_ /a_ �, Title Signed at Date WASHINGTON NATIONAL INSURANCE COMPANY it— By Signature Senior Vice President �Wf Title Evanston, IL January 19, 1988 Signed at Date F16532 (1 87) ARTICLE A The attached pages are Article A the Plan Sponsor's Plan Docuin el T1.helP�llan Sponsor certifies that the Covered Benefits described therein were first in effect on The attached pages replace those which were previously identified as Article A or Temporary Article A It is the intent of both parties to this Stop Loss Agreement that any reference in this Article A to the prior group insurance company, no matter how named shall be deemed to mean "Plan Sponsor Any and all use of terms referring to "insured" or "insurance" shall mean coverage under the Plan Sponsor s Plan PLAN SPONSOR By Signature ���� J) �. Title Signed at Date WASHINGTON NATIONAL INSURANCE COMPANY 144— By Signature Senior vice Presidents Title Evanston, IL January 19, 1988 Signed at Date F16531