1989-0392646L
NO X9 `o3q
AN ORDINANCE AUTHORIZING THE MAYOR TO EXECUTE AN APPLICATION TO
ENTER INTO A CONTRACT BETWEEN THE CITY OF DENTON AND SOUTHERN
RISK SPECIALISTS INC FOR A STOP LOSS POLICY, AND PROVIDING FOR
AN EFFECTIVE DATE
THE COUNCIL OF THE CITY OF DENTON HEREBY ORDAINS
SECTION I That the Mayor is authorized to execute an
appl caation to enter into a contract between the City of Denton
and Southern Risk Specialists Inc for a stop loss policy, under
the terms and conditions contained in the specimen of said
policy, a copy of which is attached hereto
SECTION II That this ordinance shall become effective
imme ate y upon its passage and app al
PASSED AND APPROVED this the ;ay of , 1989
RAY S YP 'NS, /MAYOR
ATTEST
IN
ER
ETAR
RY
APPROVED AS TO LEGAL FORM
DEBRA ADAMI DRAYOVITCH, CITY ATTORNEY
BY
LEXINGTON INSURANCE COMPANY
200 State Street
Boston Massachusetts 02109
EXCESS LOSS INDEMNITY
APPLICATION
The Applicant is applying for a policy providing the insurance specified below
I Name of Applicant CITY OF DENTON
Address 324 E McKinney, Denton, Texas Zip Code 76201
Type of Business Municipality
Other Locations Yes No X
If yes specify all locations
2 Plan Administrator August International
Address 1059 N Central #400, Dallas. Texas Zip Code 75206
3 Broker Southern Risk Specialists Inc
Address 1999 Bryan Straet_ Suite 1820. Dallas. TX Zip Code 75201
4 Initial Enrollment 705 Minimum Enrollment
(A) SPECIFIC EXCESS INSURANCE
(1)
Specific Retention Amount per Covered Person for the
$
60,000
Policy Year
(2)
Limit of Liability
$
940,000
(3)
Reimbursement Factor
100 %
(4)
Monthly Premium Rates Payable per Covered
Unit for the Policy Year
❑ Composite Basis ❑ Single/Family Basis
$
9 20
(5)
Monthly Optional Transplant Endorsement Rate
N/A
Payable per Covered Unit for the Policy Year
$
SA 1OU887
(B) AGGREGATE EXCESS INSURANCE
(1) Monthly Aggregate Retention Amount Factor
(2) Anticipated Annual Aggregate Retention Amount
(3) Minimum Aggregate Retention Amount
(4) Limit of Liability
(5) Reimbursement Factor
(6) Monthly Premium Rate Payable per Covered
Unit for the Policy Year
(C) MINIMUM PREMIUM
(D) COVERED BENEFITS
IN Medical ❑ Dental ❑ Weekly Indemnity
❑ Prescription Drugs ❑ Other
(E) PAYMENT BASIS
❑ Incurred and Paid ❑ Paid 13 Other 15
(F) Endorsements
❑ Optional Transplant ❑ Other
$ 288 68
$ 2,442,233
$ 2,075,897
$ 1,000,000
100
$ 2 93
$ 87,227
12 - 3 month Run In
5 Proposed Effective Date 3/1/89 subject to Lexington acceptance
6 Deposit of $ 37,759 is enclosed to apply to the first payment under the Policy if issued
i
Date at the day of~~ , 19d~?
(Signawrc of Surplus Lines Licemee
Api
BY
TN
s®utheen risk specialists inc.
telex 682 9273 1999 Bryan Street
telex 620 48087 Dallas Texas 75201
Com
CCL+WM. The LBxi gWR Insurance Cfl1mAaR1Y
INSURED CITY OF DEN110N
ADDRESS 324 E MCIMMY, DENTON, TEXAS 76201
COVER N3TE NMMM TERM EFFE(!1'IVE DATE EXPIRATION DATE
864 2234 60 DAYS 4/1/89 6 /1/89
INITIAL ENROLLMENT 705 miNimaK ENROLIMENr 599
Coverage is only applicable to the category for which a premium rate is
shown If no premium rate is shown, coverage is not provided for that
category
(A) SPECIFIC EXCESS INSURANCE
(1) Specific Retention Amount
for the Policy Year
(2) Limit of Liability
(3) Reimbursement Factor
(4) Monthly Rates Payable
for the Policy Year
per Covered Person
Composite
single
Family
(5) Monthly Optional Transplant Endorsement
Payable per Covered Unit for the Policy
(B)
$ 60.000
$ 940.000
100
$ 9 20
$
Rate
Year $ N/A
(1)
Monthly Aggregate Retention Amount Factor
$
288
68
(2)
Anticipated Annual Aggregate Retention Amount
__2.442 .
233
(3)
Mininnmm Aggregate Retention Amount
$
2.075.
897
(4)
Limit of Liability
$
1.000,
000
(5)
Re=bursement Factor
100 $
(6)
Monthly Premium Rate Payable per Covered Unit
for the Policy Year
$
2 93/PE
R/EE/ND
(c) mn
max PREmm
$
87.
227
(D)
(X) Medical ( ) Dental Weekly Indemnity Prescription Drugs
(E) PAYMENP BABIS
( ) Incurred and Paid ( ) Paid (X) Other 15J12 - 3 MDNTH RUN IN
(F) ENDORSEMENTS
( ) Optional Transplant ( ) Other
(a) Conditions precedent to the binding of coverage under this Cover
Note *SEE PAGE 2
(H) ADMINISTWOR OF BENEFIT PLAN
This Cover Note states the coverage provided by the company on the
date of issuance, subject to policy terms and conditions, and shall be
automatically cancelled and superseded by the Policy when issued In
no event shall this Cover Note remain in effect for a period in excess
of sixty days from the Effective Date specified above
AAA
multi-market professionals
BRANCHES IN HOUSTON & TULSA
(214) 220-6111
fax (214) 954 0094
Cancellation: This Cover Note may be cancelled by either the Insured
or the Company by advance written notice to the other In the event
of cancellation, the earned premium will be computed short rate if
Cancelled by the Insured and pro rata if cancelled by the ocupany.
BROKER: sound RN RISK BpB Tar.'*STS, nic.
ADDRESS 1999 BRYAN STREET, SUITE 1820, DALLAS, TMW 75201
Dated at SOUTHERN RISK SPECIALISTS this 19TH day of JANUARY 1989
i
riz Signature
* 1 Information that was requested on the proposal of 11/18/88
2 Surplus Lines Tax and Stamping Fee
U XINGTON INSURANCF (OMPANX
200 St III, StrLLt
Boston M M uhusLtts 02109
EXCESS LOSS INDEMNITY POLICY
In eonvder tnon of the pavmLnt of premium the st.ttements to thL tpphL thon t eopv of "huh is ntILhLd to tnd
m tde t p utof this Pohcy ltd subJeu to the, terms conditions tnd thnut tnons of this Pohc} Lexington Insur lust
Comp un hLrein LIlled the Compam dots msurL
Insured
Pokes #
Address
IhehtstpnnuntolptLmtumtsdutan(-Ili rhttorLtli EIILLtneDttesho"nintheScheduletndallothu
pienuums ue due and pavablt is xt,11( h L Pavmtnt of PrLmnnns provision "hilt the Pohcs is in torte
ThL POkLV Year shall hegtn ,Md LndV~1201 a m Sttndatd 7nnt it the address of thL pnnupil ohtLL of thL
N tmtd Insured %
C >untLrstgned at By
AuthonzLd RLprtsentanve
SA 100/4 87
I - D( I INITIONS
BF Nl 1 11 Pt AN( Hlso L tllcd thL PI nt) mt- tits thL NLIf fro, hLII llt, thL N llnLLI 111SI Rd If IS tuLLLI to pIOXIdL undu
I III in Of huttllts for the Covered L nns is dehned m thL Nlnkil 101111 of Such [)IM "111L11 1N 111 LHL1t On thL F TILL
IINL DILL 01 this PohLv tneludntt im unendnwvts to Such PI nt
III \1111 PIANPAYMINISON \NIN(URRI1) \NDPVIDI3\SlSniein, foi IPohuN,if tho- Told 111101.1111
Of I'LlILIIts to Wh1L11 C ONUed Units 01 C o%LtLd PuSOns hLLOI1IL Lnnt[Lot undu thl. PI to SIT hlLLt to IM 1111111 molts Of
this Polies Sueh u110unt of hLnLhtn sh ill only InLludc the LI ILIhIL 1 vpl.nNt-S mLurrl.d on of 1larthL I ItLLnvl. D el.
Of this PoI1LN Hnd p lid cuing the Polies Ye it Such unount Of buHt-htS sh ill not melucle dt-duLuhlLS LOlon,tir inLL
ttltOlinh 01 inv 0111L1 expenses 01 (.I llmi NhiLh HrL not fumhudxd uncle tIlL terms of the PI In not Sh ill it mLludL
LApL If SLs vN h 1Lh ire rtimburs thh, tloni im othuunu LL No Lost of L I it in p nmLnt )r LxpLIISL Of but Iuo [IS sh i l l hL
naluLILd An Ethglbit- FXPwiu Ndll he Lonsldered to hL 1nLtIIIo d It thL unit- the SLtti1LC of IhL utpph to Nh1Lh It
ILI nLS is provided Dritls or LhcLks ISSULd Still] ho Lounted is 111101-IntS p old Ind th, D uL of INSLIL OI L iLh 111 Ilt Of
Lhu.k SIT 111 hL deLmed thL date of piNmutt
D NI F OI ISSUE ll ins the of itu)f ISSLI HILL of H LI umS LIlLLk ordt flip ud hLUUSL Ot i hLihlL i xpLn,LS plovldL I
Ili n thL LhLLk or drift 1s dLIIVLILd unnudI Ikk TO the ptNLL Ind pud bN IhL h ink upon Nhich it 1s 111 mri
f 1 161131 I I XP[ NSLS mL ins thl. Lh IILLN NhtLh irL LOVLILd Ind p ud undu IIIL PI in SuhlcLtto im Innu HnonS of
this PohLv
(OVi RI D UNIT TnL1Is to unpIONL1 in LmplovLL Ind [ITS 01 hLr dLpuldcnh Of ,u,h Othu JLhnLd 111111 11
Iglud upon bLtWLLll the Compun told the NnnLd InsulLd
NI MI3I R OI C OVFRF D UN1 FS ml. Ins the tot HI nuinhu of ( owLLl 1, mtS cNlSnnt 111 Ills 011L puhLL month 111
\timhL1 of ( ovelul UnnS lot ihL hest po11LN month of tit( PohLv )c u 1s homl IS Inul 11 1 I11nIIIIISIl1 11 thI
SLh,JuIC I hl. Numher Of ( oNUUI l flits 101 Suhsu.luurt pol L [11 )11111 N1 I hL IuLn11mL11 1 mI I till 1 1 1
UI Id of , Nfth IhL JLt111111Un of ( )kuLd Units 111 I N11h 1h L,I_I MIN 1 tit 11 11 LI1 , 1 b 111 n
( I)\ I RI D PI RSON m, n, L t It 1),i on mdmdu 1111 NhL ( L 1 L I 1 It 111 1
I I i il 1 (OLC , I l 1111
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~ I 1 ( ULd I Illh 1111 ,OI ~ 1117111 I I th~ V I ~ 111 it 1 L A 1 1~ I RLI Ill
111111 1l'
No
VIOVIIll N V(I(IRI(IA11 R1 11 AIii)A -`ISMj IM 11 111 11)l Iu)b 1 it I l.I LI I I 1
I I Wd nnllf1h11L11 hN wLh C )NLICd 1111 Lt . 11dnn Mmithly A__11_11 R 1l.11 1 I Am, I 111
VIIVIMIM V(1(IRI(IA11 RI 11AIIO h I m1I11 IhL nwen 11InL11 n 11 >Lh1It I LL11 11 1 111
11111 IL 1 hN the A tntLd In I L11 11_11 LL Ot hON 1111_ thL PL It 11111 111 In 1111
1AAt V1 \06RI O V 1 I RI IT N I JOA \MOt A 1 101 Ill, Po 1LN NL 1 of ills 11 L ti 1I I of If Ill I'll 11,
mm 1)L1 111 11 1 InLLHLd Junn_ hL PP11LI NL it ml. 111, Ili It I1L 111 11 c 1)L I 1 101 1 vl 1 111 11 oil I L 111 1 I L
hN 1111 V ImL I InwrLd UILLII 11,11 hN mtilnpiNIn_ till IUmh I Of 1. 11 I l 111 t N till 1 ~ IL11 I 1 0111 1 1 '
111_ Monthh \tLrLL ItL RuL1111OH AniOUnt 1 1001 tivpllLd 101 L ILh hOl1 v I v 1)W L I th1 Mn11n tint A__IL 1
RLIL 11111 \nnnn11 ShoNn 111 thL SLhL11u1L 1011L110L1 is -111tH
SPI ( 11 I( RI 11 N I ION \MOI NI ML Ills tilt- lomouni spLLlhul 111 thL SLhLLlUk- Nh1L11 11 Nh to 11run d
tilt A MILLI InStnLd pu (OvuLLI PuSOII 101 tilL P0110 NL IT
114111 OI 1 IABII Ill mL Ills IIIL tntount spulhLd 111 tIIL tiLho 11dtlk NhILh n thL m iv11rtunt p\ 11111 till lu till,
POhLN to thL N uncd InstnLd 101 thL POhLv NL u
RFIMBt1RSIMEN I IACIOR mLIns tIlL pLrLLm1_L s110Nn to IIIL SLh1dL1IL Nh1Lh VIII dLn1m1n1 thL 101111
(mount OI thL Limn of Li thlhh NhiLh %vill hL Pilot to till, N Imuf In,u1Ld st-p a tIL Ru1111)i11su17L 1)l 1 1uO1S m IN
Ipph L HLh to thL AIpLI1)L I vI ss InSUi HILL Ind SpeLthL F NLLS, IIISLII HILL
NAM1 D INSLIRI D mL ins thL InsulLd 11 tmLd 111 this 13OJILv Of uiv I lust L St Ihhshul by of 101 thL N unLJ Insu11J
undu thL BLnLht 1'I m
POI I( N N I AR ml. Ills thL pufOd 110111 12 Ill I ill Sund lord I IIIIL It Till. IddlLss OI pump tl Othu Of the N 1m1d
IIISLIILd on the FH LnvL Dltl to I_' (lI d nI Stind fill 1 imc It IIIL iddiLss of the prmuP HI othLL of thL N 1111111
Insult-d Oil IhL I xpinuon D aL is lduitdlLd in IhL SLIILdtill.
'V( I IVF IY At WORK tnL HnN Thor thL LmploNLL is pertounlnt full InnL Ill 1LIuI Ir dutlt-s of his of IlLr mini d
OLLUp ition on the F ttLLtINL F )i0. of tills PoliLv o1 on hfS or hu I ist ILLUI nil SLhLLIUILd Nod k d IL pnor to thL L ILL
tnL DnL of this PohLN
10 FAT I Y DiSABL ED me Ins th It the lndividu it IS hOSprl 11 LonhnLd or 1s tin IbIL to LngaLL 111 the norm it
ILtIN111Ls of t pLrson in Lood hCtllh of hkL HI,. Ind sLx
LEXINGTON INSURANCI COMPANY
200 Stite Stmt
Boston MissahusetAU2109
SCHLDULL - Excess I oss Indunnm Polu~
INSURED POI ICY #
ADDRESS EF 1 LC I IVE DAFF
LXPIRA ION DAtI
INI FIAL ENROL LMFN I MINIMUM ENROLLMENT
C osu ige Is only tPphe thle to (ho c itegor) for which I premium rite Is shown holow It no premuim rue is shown
caner tgc Is not provided forth it c ttegorN
(A) SPEUFIC FXCESS INSURANCF
(1) SpWfIL R, tendon Amount pu Covered Pelson for the Pohev Ye IF
S
(2) Limit of Li ibilm S
(3) ReimbursementI tctor
(4) Montltk Premmm R t0. p IN ihle p<r Cowed l nn 101 IhL 13011e~ }e IF
( )(omposite B INIS ( ) SntkleiF unlh 13 tsts S _
Monthh Option if FI Inspl int I ndorsemuit R rte P n Ible P I
C o«red Unrt hn the Pollen Ye IF S
a w~ V
IRI \(j(iRl CrAI I I XC ESS INSLiRAN(I
1) 'Monthh 1zgleLtte Retennon An i ikRly~®
A11IMP wed Annu it aLLree rte R' 'lollount ti
Mnumum ALL.ICLUe Retennon Amount S
(4) I unit of L I ihilits S
(s) Runthursunent F tetor
(6) Monthh PrcInntm Rue PIN Ihle per Covered Unit
loi the Poheo Ye it
S
C) MINIMUM PREMIUM S
(D) COVERED BFNEII7S
) Mahe it ( ) Dent if ( ) Wee6h Indemmn ( ) PR1UIpnon DntL ( Other
(F) PAYMFN F BASIS
) Inuirred Ind Pud ( ) Pcad ( ) WILT _
(I) I NDORSEMFN FS
) Option if Ir inspl mt ( ) Other
(G) ADMINISTRATOR OF BENI FIF PLAN
II - SPiCIF IC EXCFSS INSURANCE
A l hL Compatn will p IN Subfcu to tIIL terms Londhuon, ind limit tuons of this POlILS thL Speufu FxLLsS
Ben LtII Ii ins to the, N umed insured within sixh (60) d INS IItLr ILLLpt uu.c hs the ( oinp ins of thL proof oI loss
ind proof of PnlnLnt of hLnchts under the PI u)
If the SpLUftL FxLLSs BLnLht 101 the POI1LS YLaror it tenon thucot is the Buuht PI ui P nniuitS On An InLUIICd
And P ud B Isis for I COVLILd Person ILSs the Speuhc RLnmClon Amount multiplied by the Reimburse m Ult
I ietou and not LxLeedmg the Limit of Li ibilrts speuht,CI under SpLUhL LxLLss insurance in the
Schedule
C It I Covered Person mcurs EhLible Expenses I smEle Speuhc RuLntion Amount shill ipply for such CONULd
Peron to those Fligihle FxpLnseS which ILL incurred ind pud Llurml, the POIILS NLIr
III - A(( RFGAiI, EXCESS INSURANCE
A Aftcr the LAW Of the POII y Ye a term ui ition or c inLLIt mon the Comp im will p iy to thL N mILd Insured the
ALtiuL~ ILL FXLLS, Beneht of ins within sixty (60) d rys titer th it Conip my S ILL pt mLe of tht proof of loss and
proof of piymuitS of buu fits untie the Pl in sublet to the tLrms conditions ind limn irons of this
PoIILi
B H IL AggiLgut FxLLSS Buuht for the Pohcs Ye Ir or triLhon thereof IS thL BLnLht Plan Ptvnunts On An
InLUHcd And Pud B isis IcsS (I) thL Annual AggrLgate RLttntlou Amount Intl (2) ihL SpecduL ExLess Beneht
which h is been or will bL rumbursLd by the Compurv undcr thL SpLUhL ExLCSs lnsurlnLL mulupliLLl by thL
RUnCihuntnunt I ictor ind not LXLLUhnL tlIL [ nnft of Lt Ihihh SpLUhCd undo A~tLLItL I xLLsS InsurloLL 1n
thL lLhcdulL
IN - I INil I XIION S OF (ON FR1( F
I I c ( onip ins h is no 1(sponsihilm o1 nh1~ unCIU i111h PohLS tU 1LImhnI,L dnLUh Im CON Lred KI 1m
of pioNick i of protLS,lon II 01 nad1L II SL r ins hLnLtI is wh1L h [111 \I iLd iI1,IIIL(I h IS IlO-Ld to Punldc
1111011 fhL (Lrm, of t1% PI in [hL ({n t u11L It Ihilm hLi-LUMILI n ui thL N tmLCI Inwud suhlLLt to ihL
ILrmS Conditions and Inns sum i L P)I1Ls
B I I 1 C osL rLtl Puum 1s not ALu 01 k or iS tot Ills I)IS u111kCl on thL [ IILLnsL 1) uL Of 011, PoIiCS t 11_11111
tl'
I xplnu„h 111 mLludc is Z
xpuius sum rut II tu th1 d It, IhL u1sUU1 PL SOn rctulm to wort. full umL
oI thL lot it [)is thilln `et d the ( oscrW PLrson HILLIS thL LhLlhlhh 1LyuItLIuL1It, of thL PI 111
( ( osL1 ILL of CSpLnuS for trL Innuu of MLOt II Ind NLrsou, C onditions 1s 11miILd to S2s 00000 in L\LL,S of
IhL SpLUhL RLILntlou Amount
N - F X( I I SIONS
1 his PolfLS will not lumhursL 0% N truLd InSUfCd for ans loss 01 LspLu,L L iuSLd hs or rt,sultml from uis
OI tltL following
I I xpuisLS' mcuncd whsle thL PI in is not in tOILL
_ I xpcnsL, resulting from thL prosrsion of wLekly mLOmL hLnLIOS or im denial vision hL irml, or prtscrlption
druC plogiam unILSS SpLUhL illy uidorsed hLreon
3 L 1 ibl11ts issumLd hs thL Named Insured under my contr ILt of sLrvtcL igrtLm,nt other th in thL PI in
4 1 XPLmLS whuLh ire b used upon my nontomP11 mLL with IM ILA 11 sit ltutL of rLgUl ttion
S I xpwuLs resulting from sLrvuLLS or Supplies which ire not n1LdiL ills nLLLSs irv irL in LxLL,s Of the usual and
Lustom Irs Lit irgc for the IOL il[ty where tdmintuered or ILL in LxLLSS of the PI in hLnefits
6 L xpLnuS for my ILLidLnt it bodily mlurv of sieknLsS for which the COVUUI PLrson would bL LnhtlLd to
hLnehtS undcr my WOrkCrS Compensation or OLCUP tuon it Disc use policy whLthcr or not Such pohLy IS
[Liu ills in forLL
7 ( ostof thL admmustntion of cl urns orother servtL,(s) provIdLd by NIL idmmistrItor Lonsultmt, ILLS orLxpLn
SLS Of ins litigation
8 With rLSPLLt to caLh COVLred PLrson who is elugiblL for benLhtS undcr MLdicam I benLht otherwiSL p ry Ibic
under this Policy sh III bL rLduced by the amount of my smut a ML(hcin. benefit so th it the total reimbur
SunLMS hereunder on beh ill' of I C overed Person sh ill not LXLCed onL hundred percent (1000/)) of the CovUed
Person S iLtual expLnses It will bL LonLlusrvely presumed th It L ILh COVLred Person LhgiblL for benLhtS undcr
Mtdie ILL bLL lint LovLrLd for ill p Irts of MedIL ILL to which hL 01 slit, 1s Unultd on thL L IfhLSt possible d nL
Ind thcrL titer in not unLd rich Lover ige in forLC
9 Expenses resulting from the commission of a crime or an illegal act
10 Expenses incurred in connection with a suicide or any intention illy self inflicted injuryor illness whether the
Covered Person were sane or insane when he or she committed the act
1 I Expenses for experimental procedures drugs or research studies or for any services or supplies not considered
legal in the United States
12 Expenses incurred by a live organ donor unless the donor is a Covered Person under this Policy Expenses of a
live organ donor shall not be considered as eligible expenses of the organ recipient unless the donor is without
insurance in which case a maximum of $5000 shall be considered as Eligible Expenses of the
recipient
13 Expenses resulting from heart lung heart lung Ilyer or pancreas transplants unless specifically
endorsed hereon
Vi - POLICY TERMINATION
The Policy and all coverage hereunder will terminate upon the earliest of the following
A The Expiration Date of this Policy
B Termination Date under the terms of the Payment of Premiums provision
C Cancellation date under the terms of the Cancellation provision
D The Date of termination of the Plan or
E Cancellation of the agreement between the Named Insured and the administrator unless the Company h-is
prior to such cancellation (1) agreed in writing to the Named Insureds designation of a successor admmis
trator and (2) received a cop} of the agreement between the Named insured and the successor
administrator
VII - CONDITIONS
PREMIUM The premium basis end rates for this Policy will be is st ned in the Schedule Upon termination of this
Policy the earned premium shall be computed in accordance with the premium and expos ire basis shown in tht.
SLhLdule if the carried premium exceeds the premiu the N imcd Insured shall p-iy the excess to the Com
pany if less the Company sit dl return the unbar f the premmm p uol to the Named insured subject to
the minimum premium it any shown m c
MINIMUM PREMIUM the ni IN, payable will be the amount shown in the Schedule or in the
eaent of termination or cancel) in of all monthly premium rates payable multiplied by the Minimum
Enrollment shown in the Sche ultiphed by the number of policy months
PAYMENT OF PREMIUMS Premiums ire due m advance on the first d ay of each month A period of fifteen (I s)
days will be granted for p iyment of each premium during which period the Policy will continue in force Should a
premium otherwise due not be p ud during such period this Policy will terminate without further notice on the date
the unpaid premium was due
DATA REQUIRED The Nvmed insured will in untain idequite records accept ible to the Company and provide
ans inform ition required by the Company to admmtstcr the 1301I y T he Company in iy periodically ex immc am
of the Named insureds records rel'iting to the insurance under the Policy and any claims filed under the
Plan
C l ERICAL ERROR Clerical error whether by the Named insured or by the Company in keeping any records
pert lining to the eoserage will not mvahdatc coverage otherwise v ilidly in torcc or continue coverage otherwise
s [bolls terminated
AMENDMFNTS rO THE POLICY This Pohey may be amended at any time with the mutual consent of the
Company and the Named Insured
AMENDMENTS TO THE PLAN AND ADMINISTRATIVE AGREEMENT The Named Insured will provide
the Company with a copy of the Benefit Plan The Plan shall not be ch ingcd while this Policy Is in force withoutthc
prior written consent of the Company Notice of amendment to the PI in must be given to tht. Company in wntin& it
200 St att. Street Boston Massachusetts 02109 at least thirty one (31) of iys prior to the Effective Date of the amend
ment in the event that the Company does not consent to the amcnclmcnt the Company shall be liable to p ty
benefits hereunder as if the Plan had not been amended i urthermorc the N amt.d inuired will provide the Com
piny with i copy of the Named insured s written agreement Ind ill imendments thereto with its Admmistritor
and the Named Insured agrees that a copy of any future amcnolmenrs to or ch mgc in that igreemcnt shall be pro
vided to the C ompany prior to the fimc it becomes effective
NO i IC E Ior the purpose of any notice required from the C omp ins under the provisions of this Policy notice to
the Nimed insurt.d shall be eonsidt.red notice to the Admtnistrnor
U)AIINISIR%IION OF (IAINISI NUIR IHF Pt AN
I III, N Wood Irr1ll1, I Sh III undut ik, it 111 hm,1 to ,mPlo, till S,Is1„s 01 tit Vinninsti nor ,,ho Sh III Ill
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pursuC u), 1,11011 to humor Itunst th( Ihnd Puts
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Poh,v not Shill th, [ums of this Poh,s hL wuvCd or ,hntl.Cd ,x(.,pt hs ,ndonCmutt IsSmd to Iolm I
pert of this Polls
ASSI(,NMI N I Asstgnm,nt Of mkl,st undo this POh,s Sit III not hind ihC ( 011111 1ns until IIS,Oitsult IS,ndorud
hu,(til it how,s(r th, N Imul [mild Sh III die Su,h m,unnu ds IS lffold,d M this POIICS Sh III Ippls (1) to Ili,
N In),d Inwl,d S log If r,pr,sult Iii, IS the N tm,d Insured but onk whdC mini, within the slop, 01 111', 01 IM
dut)CS IS Su,h )nd (2) wish r,spCCt to th, PIOP,rts OI 1111- N In)Cd Inwr,d to th, puum h tsnt- ptop,r tunpot m
LUSIOds th,r,of IS 111SWr,d hilt onls until III, IppOlntm,nt Ind yu Ihh, Icon of till ',g II r,Pr,S,nt u1s,
CANCELLATION This Policy may be cancelled by the Named Insured by surrender thereof to the Company or
by mailing to the Company written notice stating when thereafter such cancellation shall be effective This Pohcy
may be cancelled by the Company by mailing to the Named Insured -it the address shown in this Policy written
notice stating when not less than thirty (30) days thereafter such cancellation shall be effective The mailing of
notice shall be sufficient proof of notice The time of surrender or the effective date and hour of cancellation stated
in the noticesh II become the end of the Policy Period Dehvcryof such written notice either by the Named Insured
or by the Co pany shall be equivalent to mailing
if the Named Insured cancels earned premium shall be computed in accordance with the customary short rate.
table and proc dure if the Company cancels earned premium shall be computed pro rata Premium adjustments
may be made either at the time cancellation is effected or as soon as practicable after cancellation becomes effeL
five but payment or tender of unearned premium is not a condition of cancellation
LEGAL ACTION No action at law or inequity shall be brought to recover on this Policy prior to the expiration of
sixty (60) days after written proof of loss has been furnished in accordance with the requirements of this Policy No
such action shall be brought after the expiration of three (3) yelrs after the time written proof of loss is required to
be furnished
CONFORMITY WITH STATE STATUES if any time limitation of this Policy with respect to giving notice of
claim of furnishing proof of loss or bringing action is less than that permitted by the law of the state in which the
Named Insured resides such limitation is hereby extended to agree with the minimum period permitted by
such law
REPRESENTATIONS By acceptance of this Policy the Named insurLd agrees that the statements in the apphL t
tion and in the Schedule are his agreements and representations that this Policy is issued and continued in reliance
upon the truth of such representations and that this policy embodies all agreements existing between such Named
Insured and the Company
SERVICE OF SUITS It is agreed that in the event of the f uluic of the Companv to pay inv [mount clalmcd to be
due hereunder the Company at the request of the Named insured will submit to the jurisdiction of any court of
competent jurisdiction within the United States and will comply with all the requirements necessary to give such
court jurisdiction and all in fitters ansing hereunder sh ill be determmLd in aLLordancL with the Hw ind prauice of
such court
Further pursuant to any statute of any state territory o Psmc t of the United States which makes provision
therefor the Company hereby designates the Sinn,,yy~ mmissioner or Director of Insurance or other
officer snecified for that nuroose in the statute or,.w----- I$ f fice, as its true and lawful attorney upon whom
may be served any lawful process in an a i i &r~roceedmg instituted in any court of competent jurisdiction
by or on behalf of the Named incur n iciary hereunder insmg out of this contract of msunncL and
hereby designates Counsel Lexmg urance Company Legal Department 200 State Street Boston
M issachusetts 02109 or fits or her repr en tive as the person to whom said officer is authorized to in ul such pro
Less or a true copy thereof
IN WITNESS WHEREOF the Company has caused this Pohcy to bL signed by its PrLsidentand Secretary but this
Policy shall not be valid unless countersigned by i duly authorized reprLsentafive of the, Comp my
~ 44
Seret President
ENDORSEMENT
This endorsement effective I c r 1 A M forms a part of
ooi ~y No issued to
by Lex IngLL n Insurance Lo1+pary
Specific Run-In
It is hereby understood and agreed that in regard to Specific Excess
Insurance the total amount of 'Run-In' benefits to which Covered
Persons become entitled under this policy shall only include the
Eligible Expenses incurred on or after B/1/BB and received by the
Administrator of the plan for paymen mere than 30 days prior to
the Effective date of coverage T ligible Expenses must be paid
during the Policy Year ofll,l/B 11/1/89 as defined in Section
I DEFINITIONS of this policy
It is also understood an that the provisions of Section Iy
L TFrIONS of Loveragt Fa shall be applied as of 1E ~l A It
cld oth Pr +-~i a= +rla Etrec ti e cna F'rl ~r
Authorized Represenlabve
ENDORSEMENT
This endorsement effective M forms a part of
policy No issued to
by Lexington Insurance Company
In consideration of the premium paid, the policy is amended to include the
following additional coverage in Section V-Exclusions, item 13
SPECIFIED ORGAN TRANSPLANT COVERAGE
Subject to the provisions, conditions, exceptions, reductions, and
limitations of the policy, Lexington Insurance Company agrees to reimburse
the Named Insured in excess of the Specific Retention Anount for 100/ of
Eligible Expenses resulting from or directly related to the completion of a
heart, lung, heart-lung, liver or pancreas human organ transplant
procedures This rider provides
coverage only for Eligible Expenses incurred
while this rider is in effect and paid dining the Benefit period
Lexington Insurance Company also agr
surgical, storage, and transportatv,,
of a human organ used in an organ
rider, subject to a maximum of $
completed
s reimburse the Named insured for
directly related to the donation
plant procedure covered under this
for each organ transplant procedure
All benefits provided as st
maximum of $1,000,OUu
rider are subject to a lifetime
Benefit Period, as used herein, means file (5) days immediately prior to and
fifty-two (52) weeks immediately following a completed organ transplant
procedure covered under this alder
If a Covered Person is an Employee who is not Actively At Work or if the
Covered Person is a Dependent who is hospital confined or totally disabled on
the Effective Date of this rider, no insurance benefits shall be provided
under this rider until he or she is no longer disabled
Totally Disabled, as used herein, means unable to perform the normal
activities of like age and sex in good health
While this rider is in effect, the coverage provided herein shall apply to
all current and new Covered units
* 4f
AUTHORIZED REPRESENTATIVE
LElmavmx INSURANCE COMPANY
200 State Street
Boston, Massachusetts 02109
ADDENDA f TO
ExcEss LOSS nu)EMNITY
APPLICATION
This Addendum is attached to and forma a part of the Application of
(Name of Applicant)
Listed below are the names of.
1) all employees of the Applicant who, at any time during the period commencing three calendar
months immediately prior to the Proposed Effective Date, are not "actively at work"*, and
(2) the following who are "totally disabled"*** at any time during the period commencing three
calendar months immediately prior to the Proposed Effective Date
a) all dependents of all employees of the Applicant whether or not such employees are
"actively at work"* during the period specified in (1) above,
b) C O B R.A participants, and
c) C o B R A.** eligible participants
Also specified below for these individuals respective ailment(s) are their diagnosis current
status, prognosis, and charges to date under the Appli„pantrs "benefit plan"****
Lexington will notibe liable for any incurred by persons who were known to be not
The Applicant hereby certifies that the diaclo -below are complete and true to the
tends that these statements are its
best of its knowledge and belief The Awl,
representations and are made for the purpose B§Ftons g Lexington Insurance Comlpany to issue
the coverage applied for in this Applioa he Policy, if one is issued, will be
issued in reliance on the truth of It is understood and agreed that
~~aatively at worlx~~* or who were known be "totally disabled"*** and are not disclosed in this
Application.
Disclosures (UselrWerae aide for additional apace, if needed, in listing of names, and
identify as 1, 2,(a), 2(b), 2(0), as appropriate)
*"actively at work" in this Application means that the employee is performing full time all
regular duties of his or her normal occupation
**C O B R A means the consolidated on nibus Budget Reconciliation act of 1985
11totally disabled" means that the individual is hospital confined or is unable to engage in
the normal activities of a person in good health of like age and sex
****"benefit plan" means the welfare benefits the Applicant has agreed to provide under a plan
of benefits for the Applicants employees and their dependents and for any other covered under
such plan
signature
Date
rifle