R2007-129 2007-08-30
RESOLUTION NO. R2007 -129
A RESOLUTION OF THE CITY COUNCIL OF THE CITY OF
PEARLAND, TEXAS, AUTHORIZING THE CREATION OF AN
EMPLOYEE BENEFITS TRUST, DESIGNATING ALL MEMBERS OF
THE CITY COUNCIL TO BE TRUSTEES, AND AUTHORIZING THE
TRUST TO PURCHASE VARIOUS FORMS OF INSURANCE FOR THE
BENEFIT OF CITY OFFICERS, EMPLOYEES, QUALIFIED RETIREES
AND THEIR DEPENDENTS.
BE IT RESOLVED BY THE CITY COUNCIL OF THE CITY OF PEARLAND,
TEXAS:
Section 1. That the City Council hereby authorizes the creation of an Employee
Benefits Trust, designating all members of the City Council to be Trustees, and
authorizing the Trust to purchase various forms of insurance for the benefit of city
officers, employees, qualified retirees and their dependents
PASSED, APPROVED, AND ADOPTED this 13th day of August, A.D., 2007.
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TO~ REID
MAYOR
ATTEST:
APPROVED AS TO FORM:
YJft\.-- Ii .~
DARRIN M. COKER
CITY ATTORNEY
Exhibit
Resolution No. R2007..129
07 -0062
DECLARATION OF TRUST
I.
The City of Pearl and I ("City"), as settlor, designates the members of the City of Pearland
City Council2 to be Trustees and declares that the City holds in trust the funds described in
Schedule A attached hereto and incorporated herein by reference, which is the prope11y of the
City, and all substitutions and additions to such funds, for the purpose of providing life,
disability, sick, accident, and other health benefits to the City's officers, employees, and
qualified retirees and their dependents.
II.
PURPOSE
This is a nonprofit trust created for the purpose of providing City officers, employees,
and qualified retirees and their dependents with life, disability, sickness, accident, and other
health benefits either directly or through the purchase of insurance and to perfonn operations in
furtherance thereof.
III.
DURA TION
The Trust shall continue until tenninated by operation of law or by majority vote of the
Trustees.
IV.
TRUSTEES: COMPOSITION, OFFICERS, COMPENSATION, AND MEETINGS
COMPOSITION. The Trustees are the members of the City of Pearl and City Council,
and the telm of each Trustee is cotemporaneous with his or her term of office as a Member of the
I The settlor is the entity establishing the trust and may also be a Chapter 172 Pool, a county, a hospital district, or a
county or municipal hospital.
1 The trustees will govern the operations of the trust and may also be the Trustees of a Chapter 172 Pool, members
of a County Commissioners Court, or members of the Board of Directors of a hospital district or of a municipal or
county hospital.
Ik...:l;n;ttin!1 or I "ru:-;l Page I
City Council. Whenever a Trustee ceases to be a member of the City of Pearl and City Council,
the person succeeding him or her in office will serve as a successor Trustee of the Trust.
OFFICERS. The Mayor shall serve as Chairman and shall preside at meetings of the
Trustees and shall have all such other powers as are conferred herein or by majority vote of the
Trustees. The Mayor Pro Tern shall serve as Vice Chainnan and shall preside at meetings of the
Trustees whenever the Chainnan is absent. The Secretary shall rotate, coinciding with the City
of Pearland 's Fiscal Year, between the District Council members, skipping the Mayor Pro Tern
District, beginning with Position 1. The Secretary will oversee the preparation of meeting
agendas, giving notice of meetings to the Trustees, and the minutes of the meetings of the
Trustees.
COMPENSA TION. The Trustees shall be reimbursed for all reasonable and necessary
expenses incurred by them in the performance of their duties and will otherwise receive no
compensation for their service as Trustees.
MEETINGS. A meeting of the Trustees may be called by the Chairman or on written
request to the Chairman by two or more Trustees. Trustees shall have at least three days written
notice of any meeting. For purposes of this section, electronic mail notice is written notice.
V.
RIGHTS, POWERS, AND DUTIES OF TRUSTEES; QUORUM AND VOTING
RIGHTS, POWERS, AND DUTIES. In addition to all other powers and duties conferred
on them by this Trust document and imposed or authorized by law, the Trustees shall have the
following powers and duties:
I. The Trustees shall carry out all of the duties necessary for the proper operation
and administration of the Trust on behalf of the covered persons and shall have all
Dccli\rati\ll1 ot'Tru:-;( .. Page 2
the powers necessary and desirable for the effective administration of the affairs
of the Trust.
2. The Trustees have the general power to make and enter into all contracts, leases,
and agreements necessary or convenient to carry out any of the powers granted by
this Trust document or by law or to effectuate the purpose of the Trust. All such
contracts, leases, and agreements or any other legal documents herein authorized
shall be approved by the Trustees and signed by the Chairman on behal f of the
Trust. The Trustees may also designate another Trustee to sign such documents.
3. The Trustees shall use the Trust's funds to accomplish the purpose of the Trust, as
described in Paragraph II herein, and to operate and administer the Trust solely in
the interest ofthe covered City officers, employees, and qualified retirees and
dependents thereof and for the exclusive purpose of providing benefits to such
persons and defraying the reasonable expenses of administration of the Trust. To
this end, the Trustees may purchase life, disability, or accident and health
insurance to provide coverage for participating City officers, employees, and
qualified retirees and their dependents. The Trustees may also adopt a health
benefits plan that covers eligible City officers, employees, and qualified retirees,
and their dependents.
4. The Trustees may accept contributions to the Trust funds from any source
including contributions from covered persons receiving benefits from the Trust.
5. The Trustees shall be authorized to contract with any qualified organization to
perform any of the functions necessary for providing life, disability, sick,
accident, and other health benefits, including but not limited to excess loss
Ikclilrali\Jll oJ'Tru:;[ ..P,lg.C:)
insurance, stop loss insurance, claims administration, administrative services, and
any other services that the Trustees shall deem expedient for the proper operation
of the Trust. When required by law or desired by the Trustees, the Trustees may
seek sealed competitive bids or sealed competitive proposals with respect to
contracts required to carry out the operations of the Trust and to effect the purpose
of the Trust.
6. The Trustees shall arrange for the investing of the funds of the Trust so as to keep
the same invested according to law and at the best interest rates obtainable for the
benefit of the covered persons. The Trustees may hire money managers and shall
adopt an investment policy for its own use and that of its agents in making
investments. The Trustees shall select a depository for the Trust's funds and
provide for the proper security of any and all investments. The Trustees shall
designate signatories for the Trust's depository accounts.
7. The Trustees may purchase out of the Trust funds insurance for the Trustees and
any other fiduciaries appointed by the Trustees and for the Trust itself to cover
liability or losses occurring by reason of the act or omission of anyone or more of
the Trustees or any other fiduciary appointed by them. Any insurance purchased
by the Trustees must give the insurer recourse against the Trustees or other
fiduciaries concerned for breach of any fiduciary obligation or fiduciary duty
owed to the Trust.
8. The Trustees shall arrange for proper accounting and reporting procedures for the
Trust's funds and shall also provide for an annual audit of the Trust's financial
affairs by a certified public accountant.
Lkcl,lntiill!1 orTru~tP<lgc 4
9. The Trustees may retain legal counsel to represent the Trust and the Trustees in
all legal proceedings as well as to advise the Trust and the Trustees on all matters
pertaining to the operation and administration of the Trust.
10. The Trustees have the authority to terminate the Trust at any time.
11. Upon termination of the Trust, the Trustees shall provide for the payment of Trust
obligations, debts, losses, and other liabilities and shall provide for the disposition
of the remaining Trust funds in accordance with Paragraph IX herein.
12. The Trustees shall have the power to acquire, by purchase or otherwise, retain,
invest, reinvest, and manage, temporarily or pennanently, any interest (including an
undivided interest) in any realty or personalty; to alter, improve, repair, replace.,
abandon, and demolish assets; to sell, exchange, encumber, lease tor any period, or
otherwise dispose of any asset of the Trust, publicly or privately, with or without
notice, wholly or partly for cash or credit, without appraisal, and to give options for
those purposes; to abandon, compromise, contest, and arbitrate claims; to hold title
in the name of a nominee; to adopt policies and regulations for the efficient
operation ofthe Trust; to detennine all matters of trust accounting as established by
controlling law or customary practices; to set up and maintain reasonable reserves
tor taxes, assessments, insurance premiums, repairs, improvements, depreciation,
depletion, amortization, obsolescence, general maintenance of buildings or other
property, and any other purpose; to employ agents, accountants, brokers, attorneys-
in-fact, attorneys-at-law, tax specialists, realtors, investment counsel, and other
assistants and advisers; and to delegate powers and duties to other persons,
partnerships, corporations, and financial or business organizations.
Lkl.:lurmi\Hl unrtl~l Page:;
QUORUM AND VOTING. A majority of the Trustees shall constitute a quorum for the
transaction of business at any meeting of the Trustees and the vote ofa majority of the Trustees
present shall be required for approval of any action at such meeting. The vote of such majority
of the Trustees at such meeting shall constitute action of the Trustees as a group.
VI.
BENEFICIARIES
The beneficiaries of the Trust are the City officers, employees, and qualified retirees and
their dependents who are covered by a life, disability, sick, accident, or other health benefits plan
purchased or adopted by the Trust (also called "covered persons" herein). Beneficiaries may
make contributions to the Trust for use by the Trustees in fulfilling the purposes of the Trust. No
beneficiary shall have any claim against the funds or any other property of the Trust. The rights
and interests of the beneficiaries are limited to the insurance or health benefits specified in any
policy purchased or plan adopted by the Trustees.
VII.
TRUST FUNDS
The Trust funds consist of the funds described in Schedule A hereto as provided by the
Settlor to institute this Trust, future contributions by the Settlor, beneficiary contributions,
investment income, and any other money or property which shall come into the hands of the
Trustees in connection with the administration of the Trust. The Trustees may use the Trust's
funds as follows:
I. to pay all expenses which the Trustees consider necessary in establishing the
Trust and in administering the Trust and all reasonable expenses incurred by the
Trustees in the perfOlmance of their duties;
2. to pay premiums on any insurance policies purchased by the Trust;
Dcclaratiun orTruslPagc 6
3. to make authorized investments;
4. to pay claims under any health benefits plan adopted by the Trustees;
5. to pay for all necessary professional services, property, and equipment required
for the proper operation of the Trust;
6. to pay all legal obligations of the Trust; and
7. to pay any judgment entered against the Trust or to compromise and settle
litigation in which the Trust is a pmiy.
VIII.
LIABILITY OF TRUSTEES AND OFFICERS
The Trustees shall use ordinary care and reasonable diligence in the exercise of their powers
and the performance of their duties hereunder; and they or any former Trustee shall not be liable for
any mistake of judgment or other action made, taken or omitted by them in good faith, nor for any
action taken due to good faith reliance on third parties or for actions omitted by any agent, employee
or independent contractor selected with reasonable care; nor for loss incurred through investm~nt of
the Trust funds or failure to invest. No Trustee or former Trustee shall be liable tor any action taken
or omitted by any other Trustee. No Trustee or fonner Trustee shall be required to give a bond or
other security to guarantee the faithful pertormance of his or her duties hereunder. To the fullest
extent permitted by law: (a) the Trustee shall be held harmless and the Trust shall indemnify
each Trustee or former Trustee who was, is, or is threatened to be made a party to any
threatened, pending, or completed action, suit, or proceeding ("Proceeding"), any appeal therein,
or any inquiry or investigation preliminary thereto, by reason of the fact that the Trustee is or
was a Trustee; (b) the Trust shall payor reimburse a Trustee for expenses incurred (i) in advance
of the final disposition of a Proceeding to which such Trustee was, is or is threatened to be made
Dccl;iri\U\lll \lJ'Tru:-:t Page "7
a party, and (ii) in connection with such Trustee's appearance as a witness or other participation
in any Proceeding.
IX.
AMENDMENT, REVOCATION AND TERMINATION
This Declaration of Trust and the Trust created herein shall tenninate when and if required
by operation oflaw. The Trustees shall have the power to amend, modify, terminate or revoke., in
whole or in part, this Declaration of Trust and the Trust created herein by majority vote at a duly
called meeting at which a quorum is present. Notwithstanding the foregoing, the Trustees shall
have no power to amend Para!:,JTaph 11 of this Declaration of Trust. Beneficiaries of the Trust shall
have no right to amend this Declaration of Trust, and their approval shall not be a condition or
requirement for an authorized amendment by the Trustees.
Upon termination of the Trust, the Trustees shall pay all obligations, debts, losses, and
other liabilities of the Trust. Thereafter, the Trustees shall first use the remaining trust funds to
pay covered claims of persons covered under the City's health benefits plan that may be in effect
at the time of termination of the Trust and, then, either apply any remaining balance of the funds
for the benefit of those covered persons in such manner as the Trustees determine shall best carry
out to purposes of this Trust or pay such balance over to such covered persons on a per capita
basis. Notwithstanding the foregoing, the Trustees, upon termination of the Trust and payment
of all Trust obligations may, by vote of a majority of the Trustees, transfer the remaining funds
or any portion thereof to the trustees of any trust or trusts established for a substantially similar
purpose to be applied for uses substantially similar to those set forth in Paragraph II herein.
Lkcl;mdillll {}rTru~lmp,!gc x
X.
GOVERNING LAW
This Declaration of Trust and the Trust created herein shall be construed and governed by
the laws of the State of Texas in force from time to time.
XI.
MISCELLANEOUS
Whenever the context so admits and such treatment is necessary to interpret this Declaration
of Trust in accordance with its apparent intent, the use herein of the singular shall include the plural,
and vice versa, and the use of the feminine, masculine, or neuter gender shall be deemed to include
the other genders.
The captions or headings above the various Paragraphs of this Declaration of Trust have
been included only to facilitate the location of the subjects covered by each Paragraph but shall not
be used in construing this Declaration of Trust.
If any clause or provision of this Declaration of Trust proves to be or is adjudged invalid or
void for any reason, such invalid or void clause, provision, or portion shall not affect the whole, but
the balance of the provisions hereof shall remain operati ve and shall be carried into effect insofar as
is legally possible.
IN WITNESS WHEREOF, the undersigned parties have executed this Declaration of Trust,
consisting of twelve (12) pages and Schedule A attached hereto, on the dates of their respecti ve
acknowleclgments below. By joining in the execution of this Declaration of Trust, the Trustees
acknowledge receipt of the property described in Schedule A, signify acceptance of the Trust
created hereunder, and covenant that the Trust will be executed with all due fidelity. This Trust is
effective as of the last date of signature below.
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Mayor Tom Reid, Settlor
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Helen Beckman, Trustee
THE STATE OF TEXAS *
*
COUNTY OF BRAZORIA *
This instrument was acknowledged before me on AUb'1lst 13,2007, by Tom Reid, Mayor of
the City of Pearland on behalf of Settlor.
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This instrument was acknowledged before me on AUbTUsts 13, 2007, by Steve Saboe,
Trustee.
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SCHEDULE A
The following is a list of the assets initially transferred by the City of
Pearland, Settlor, to the Trust:
City of Pearland's first month (October 2007) contributions for Employee,
Dependent, and Retiree Medical/Pharmacy Benefits, Dental Benefits, Vision
Benefits, and Life Insurance Benefits.
City of Pearl and Employee, Dependents and Retiree first month (October 2007) of
Plan Year's payroll deductions or contributions for Medical/Pharmacy Benefits,
Dental Benefits, Vision Benefits, and Supplemental Life Insurance Benefits.
Dcclarali\m oi'Trust ... P,lgc 13
Exhibit
Resolution No. R2007 -129
07 -0062
We want you to know
)\ Aetna:
IMPORTANT FACTS ABOUT EZenrolfID
1. As part of your participation in this program, you will need to keep either paper or
electronic copies of the actual enrollment forms that your employees use to enroll for
coverage. You are responsible for the accuracy and timeliness of enrollment
information submitted to Aetna. To meet regulatory requirements, the copies must be
maintained for at least seven years.
2. If your plan is insured you must either (1) use Aetna-supplied forms in paper format
or electronic format or (2) agree to incorporate the following four points into your
enrollment materials.
. Name(s) of the Aetna company offering the insurance coverage.
. State-specific fraud warning statement.
. A statement that the terms of the insurance documents will govern the
rriember's rights and responsibilities.
. An acknowledgment that participating providers are not agents or employees
of Aetna and that network composition can change.
Sample template language is attached below.
Customer Signature & Title
City of
Pearland Employee
Benefit Trust
g'2.3 -.&;07
Date
ompany Name:
City of Pearland
I/we
hereby a~~ you to release
~ o~ SU<r: & Associ~tes
ustomer Signature
enrollment
information
to:
August 23,2007
Dear Aetna:
This letter serves as our authorization for Aetna to enroll employees without an employer
signature on the enrollment forms. .
This is a blanket approval for all forms submitted, prior to the effective date, to be
enrolled as if our officer signed them. This hereby indemnifies Aetna of any
equivocation found subsequent to the enrollment process on members who should not
have been enrolled.
Thank you for your assistance with this matter.
~SiJ: f2~
Tom Reid
Chairman
City of Pearl and Employee Benefit Trust
3519 LIBERTY DRIVE. PEARLAND, TEXAS 77581-5416.281-652-1600. www.ci.pearland.tx.us
ft
" Printed on Recycled Paper
Group Questionnaire
~
Answer the following questions to the best of your knowledge for all eligible employees and their dependents (proprietors, partners, corporate
officers, employees, spouses and dependent children).
IMPORTANT: Your answers to these questions must include all COBRA and State Continued individuals covered by your present plan.
[X I Yes
I No
A. Are any employees, dependents or COBRA continuees considered disabled?
1 Retiree
[X I Yes
I No
B. Are any employees or dependents contemplating treatment or hospitalization, been advised to seek treatment, or
been scheduled for hospitalization and/or surgery?
[ XI Yes
I No
C. Are any employees or dependents pregnant? If "Yes," how many?
[X I Yes
I No
D. Has any employee missed 10 or more consecutive days of work in the last 12 months due to injury or illness?
[X Yes [ I No
E. Has the Group or Broker/Agent requested and/or received paid claim information within the past 6 months
from your current carrier? If yes, please provide all claim information received.
[X I Yes [ ] No
F. Within the past 12 months, has any employee or dependents had a serious continuing claim (Le., chronic:
or ongoing condition likely to cost $10,000 or more per year for treatment) due to a mental or physical disorder? If yes,
check the appropriate box(es) below As defined in plan specification documents.
A Immune
I Alcohol Abuse
] Arthritis
I Back, Neck
] Blood
] Bone / Joint
] Brain
] Cancer! Tumor
ar lovascu ar
I Diabetes
I Drug! Substance Abuse
I Epilepsy
I Ears / Eyes
] Emphysema! Pulmonary
] Heart Disease
I High Risk Pregnancies
n ern Ity
I Intestines
I Kidney
] Liver
I Lungs
] Lupus
] Mental! Nervous
] Migraines
euro oglca
] Pancreas
] Skin
] Stomach
] Stroke! Paralysis
] Venereal
] Other (detail below)
If you answered .Yes. to question B, C, D or F, please provide the following information for each individual with a likely serious continuing condition.
Use additional sheet if necessarv.
$ Amount
Dates of Names of of Prior
EE or Dep Age Site Location Nature of Condition Treatment Medication Claims Current Status
Aetna, Inc. will rely on the information provided to determine whether a proposal will be issued. The responses are assumed to be correct.
If errors or omissions are subsequently found, Aetna, Inc. reserves the right to revise rates or rescind the quote.
Prospective Applicant Signature
5l'.23 r 200
Date
Sales Representative Signature
Date
March-05ed Group Questionnaire
MASTER APPLICATION
Texas DMO
Point of Service (POS) Plan Option
Due to Texas-specific regulatory requirements, all Texas contract sitused cases and all cases with any Texas lives being
offered a DMO plan must also be given the option on whether to accept or decline a dental point-ot-service (DPOS) plan
tor their Texas employees.
The POS dental plan is not part ot our standard product offering at this time; however, we have created a plan specifically
and only tor Texas members to accommodate this state requirement.
In order to comply with the Texas dental POS regulatory requirement, customers must be offered the option to select a
dental point-ot-service plan tor their Texas employees. This would be in lieu ot another DMO plan option. However, the
TX POS plan selection by the plan sponsor is not required. It the plan sponsor opts to offer this plan, only Texas members
will have the POS option available. No variations trom the standard point-ot-service option will be available -- even on an
exception basis.
The point-of-service is composed of:
. In-Network - DMO Plan 51 with no office visit copayment; orthodontia is not covered
. Out-of-Network - 70/50/50 indemnity-style coinsurance plan with a $200 deductible (3x, family) and a $500 annual
maximum; orthodontia is not covered.
Two-tier Three-tier Four-tier
Single $22.52 Single $22.52 Single $22.52
Family $56.51 EE + 1 $43.47 Couple $45.52
Family $64.42 P/Ch{ren) $43.73
Family $66.72
Note that the Texas point-of-service option must reflect the tier structure of the remainder of the group.
The customer must complete the Texas DMO Point of Service agreement indicating whether or not they would like to
select the point-of-service offering tor their Texas employees. If the customer selects the point-of-service option, please
notify Dental Underwriting immediately to ensure the plan is identified during the new business process. (Dental
Underwriting must indicate this option on the NB358 as a non standard feature for Texas members.)
Customers who purchase the point-of-service plan for their Texas employees may choose to offer the point-of-service
plan on either a standalone basis or as part of a Dual Choice/Dual Option arrangement. Due to the conflict with the
monthly switch option ot FOC, the point ot service option will not be available as the alternate plan under the
Freedom-at-Choice plan design.
rev: 0:5-12-03
[AETNA DENTAL INC.]
Texas DMO NOTICE OF ACCEPTANCE OR REJECTION
Point of Service (POS) Plan Option
In accordance with the Texas-specific regulatory requirements, the Contract Holder accepts or rejects, as
indicated below, the Point of Service (PaS) Plan Option which [Aetna Dental Inc. ] has made available as
mandated by these regulatory requirements:
01 accept the optional Point of Service (PaS) Plan Option for my employees.
01 reject the optional Point of Service (PaS) Plan Option for my employees.
Contract Holder:
City of Pearland Employee Benefits Trust
R (Plea'. P,;ot)
~)~ ~
Signature:
Date:
8--- ).3" :2a?1
tx pas option
rev: 05-12-03
Application For Group Coverage
Policy Number (for Aetna use only)
Application is hereby made to AETNA LIFE INSURANCE COMPANY,
of Hartford, Connecticut for the group coverage(s) specified below.
1 For For For
Employees Dependents Retirees Kind of Coverage
Contributory D D D Basic Term Life Insurance *
Non-Contributory D D D *Dependents' Maximum subject to state law.
Contributory D D D Supplemental Term Life Insurance *
Non-Contributory D D D *Dependents' Maximum subject to state law.
Contributory D D Not Accidental Death & Personal Loss Coverage
Non-Contributory D D Available
Contributory D D Not Supplemental Accidental Death &
Non-Contributory D D Available Personal Loss Coverage
Contributory D Not Not Long Term Disability
Non-Contributory D Available Available
Contributory D Not Not Short Term Disability
Non-Contributory D Available Available
Contributory D D D Long Term Care
Non-Contributory D D D
Contributory D [K] [K] Medical Expense Coverage
Non-Contributory [K] D D
Contributory D D D Other
Non-Contributory D D D
Application is hereby made to the following companies for the kinds of group dental coverage* specified below
Aetna Life Insurance Company of Hartford, Connecticut Aetna Dental of California, Inc
Aetna Dental Inc. (New Jersey) Aetna Dental Inc.
(Maryland)
(Missouri)
Aetna Health Inc. (Arizona)
(North Carolina)
(Texas)
Aetna Health Inc.
*Aetna Health Inc. DMO, Aetna Health Inc. PPO Dental and Aetna Health Inc. Indemnity Dental are underwritten by Aetna
Life Insurance Company. In the States of AZ, CA, GA, MD, MO, NC, NJ and TX, Aetna Health Inc. DMO is undHrwritten
by the companies indicated above.
For For For
Emplovees Dependents Retirees Kind of Coverage
Contributory D [K] [K] Dental Expense Coverage
Non-Contributory [K] D D
2 Applicant
City of Pearland Employee Benefits Trust
Address
3519 Liberty Drive
Pearland Texas 77581
3 The purpose of the application is to request: a. ~issuance of new coverage
b. Dchange in existing coverages
c. Dextension of existing coverages to additional groups of
employees
d. Dreplacement of existing group life insurance
(FL Contract Situs Only)
4 This application includes the fOllowing member employers (Any entry in conflict with applicable law cannot bEl included.)
Located At
Located At
Located At
5 All of the regular, full-time active employees of any employer mentioned above shall be eligible to participate as to the
coverage hereby applied for, except the following (State here, by coverage, the class or classes excluded).
6 Agent(s) of Record
Name: Burke Sunday, Sunday & As Signature
General Agent
Name: Signature License #:
7 The Applicant agrees that at no time shall any employee be permitted or required to contribute for non-contributory
coverage; or, unless the change is approved in writing by Aetna at its Home Office, to make contributions for
contributory coverage at a rate higher than the initial contribution rate applicable for the employee's then current
coverage. It is agreed that no coverage shall become effective as to any person who is not then a bona fide, full-time
employee, regularly performing the duties of his or her occupation, unless otherwise specifically provided in the Group
Policy or Contract or Group Agreement. All statements herein shall be deemed representations and not warranties.
Any person who knowingly and with intent to defraud any insurance company or other person files an application for
insurance or statement of claim containing any materially false information or conceals for the purpose of misleading,
information concerning any fact material thereto may have violated state law.
KENTUCKY & PENNSYLVANIA CONTRACT SITUS - Any person who knowingly and with intent to defraud any
insurance company or other person files an application for insurance or statement of claim containing any materially
false information or conceals for the purpose of misleading, information concerning any fact material thereto commits
a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.
NEW YORK CONTRACT SITUS - As to Accident and Health insurance coverage, any person who knowingly and
with intent to defraud any insurance company or other person files an application for insurance or statement of claim
containing any materially false information, or conceals for the purpose of misleading, information concernin~1 any fact
material thereto, commits a fraudulent insurance act, which is a crime and shall be subject to a civil penalty not to
exceed five thousand dollars, and the stated value of the claim of each such violation.
NEW JERSEY CONTRACTS - Any person who includes any false or misleading information on an application for an
insurance policy is subject to criminal and civil penalties.
FLORIDA CONTRACTS - Any person who knowingly with intent to injure, defraud, or deceive any insurer files a
statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony
of the third degree.
COLORADO CONTRACT SITUS - It is unlawful to knowingly provide false, incomplete, or misleading facts or
information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties
may include imprisonment, fines, denial of insurance, and civil damages. Any insurance company, or agent of an
insurance company who knowingly provides false, incomplete, or misleading facts or information to the policyholder
or claimant for the purpose of defrauding or attempting to defraud the policyholder regard to a settlement or award
payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the department of
regulatory agencies.
/J/1
(JV~
7
License #: 35~~O
Signed at
Pearland Texas
Ci
By
Chairman
Official Title
Your premium pur ases insurance coverage from Aetna, as well as the services of any Aetna-appointed licensed
independent agent or broker identified in the Application For Group Coverage. Aetna has various programs for
compensating producers (agents, brokers and consultants). If you would like information regarding compensation
programs for which your producer is eligible, payments (if any) which Aetna has made to your producer, or other
material relationships your producer may have with Aetna, you may contact your producer or your Aetna account
representative. Information regarding Aetna's programs for compensating producers is also available at www.aetna.com
We appreciate your business and the opportunity to serve you.
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MASTER APPLICATION
Texas DMO
Point of Service (POS) Plan Option
Due to Texas-specific regulatory requirements, all Texas contract sitused cases and all cases with any Texas lives being
offered a DMO plan must also be given the option on whether to accept or decline a dental point-of-service (DPOS) plan
for their Texas employees.
The POS dental plan is not part of our standard product offering at this time; however, we have created a plan specifically
and only for Texas members to accommodate this state requirement.
In order to comply with the Texas dental POS regulatory requirement, customers must be offered the option to select a
dental point-of-service plan for their Texas employees. This would be in lieu of another DMO plan option. However, the
TX POS plan selection by the plan sponsor is not required. If the plan sponsor opts to offer this plan, only Texas members
will have the POS option available. No variations from the standard point-of-service option will be available -- even on an
exception basis.
The point-of-service is composed of:
· In-Network - DMO Plan 51 with no office visit copayment; orthodontia is not covered
· Out-of-Network - 70/50/50 indemnity-style coinsurance plan with a $200 deductible (3x, family) and a $500 annual
maximum; orthodontia is not covered.
Two-tier Three-tier Four-tier
Single $22.52 Single $22.52 Single $22.52
Family $56.51 EE + 1 $43.47 Couple $45.52
Family $64.42 P/Ch(ren) $43.73
Family $66.72
Note that the Texas point-of-service option must reflect the tier structure of the remainder of the group.
The customer must complete the Texas DMO Point of Service agreement indicating whether or not they would likE~ to
select the point-of-service offering for their Texas employees. If the customer selects the point-of-service option, please
notify Dental Underwriting immediately to ensure the plan is identified during the new business process. (Dental
Underwriting must indicate this option on the NB358 as a non standard feature for Texas members.)
Customers who purchase the point-of-service plan for their Texas employees may choose to offer the point-of-service
plan on either a standalone basis or as part of a Dual Choice/Dual Option arrangement. Due to the conflict with the
monthly switch option at FOC, the point at service option will not be available as the alternate plan under the
Freedom-at-Choice plan design.
rev: 05-12-03
[AETNA DENTAL INC.]
Texas DMO NOTICE OF ACCEPTANCE OR REJECTION
Point of Service (POS) Plan Option
In accordance with the Texas-specific regulatory requirements, the Contract Holder accepts or rejects, as
indicated below, the Point of Service (PaS) Plan Option which [Aetna Dental Inc. ] has made available as
mandated by these regulatory requirements:
01 accept the optional Point of Service (POS) Plan Option for my employees.
01 reject the optional Point of Service (POS) Plan Option for my employees.
Contract Holder:
City of Pearland Employee Benefits Trust
[2 (PI.". Printl
c=:::>)~ ~
Signature:
Date:
8~ l.3~ :2a?1
tx pas option
rev: 05-12-03