R2003-0105 07-28-03RESOLUTION NO. R2003-105
A RESOLUTION OF THE CITY COUNCIL OF THE CITY OF PEARLAND,
TEXAS, APPROVING DENTAL INSURANCE RENEWAL RATES WITH
FORTIS BENEFITS INSURANCE COMPANY.
BE IT RESOLVED BY THE CITY COUNCIL OF THE CITY OF PEARLAND, TEXAS:
Section 1. That the City received a renewal rate for dental insurance benefits and
such rates have been evaluated.
Section 2. That the City Council hereby adopts the renewal rate for dental
insurance benefits in the amount described in exhibit"A", attached hereto and incorporated
for all purposes.
PASSED, APPROVED and ADOPTED this the 28th dayof
July ,
A.D., 2003.
TOM REID
MAYOR
ATTEST:
APPROVED AS TO FORM:
DARRIN M. COKER
CITY ATTORNEY
Group Insurance Preliminary Application
· ':,"-'-';:': F 0 RTI S
Solid partners, flexible solutionsTM
Policy no. I744 (New Issue / Amendment)
1. Exact legal name of applicant (Explain if different from deposit check.) Employer Tax ID no.
CITY OF PEARALAND 74-6028909
2. Full address (main office) Note: If PO Box is used, also include street address.
Address 3519 ·LIBERTY DRIVE
City PEARLAND County BRAZORIA
State TEXAS ZIP 77581
Phone no.
(281) 652-1617
Fax no.
(281) 652-1703
3. Applicant is:
[] Corporation D Partnership [] Proprietorship [] Sub-Chapter S Corp. [] Prof. Corp. orAssn.
[] Trustee(s) [] Association [] Union (submit by-laws, trust agreements, board minutes, etc.)
[] Government Funded Non-Profit Organization X3. Non-Profit Organization [] Political Subdivision
[] Limited Liability Company [] Limited Liability Partnership [] Limited Partnership
4. Nature of business (Give details of service or product, manufacturing process, materials used and any hazards.)
SIC code 913]
5. Indicate affiliates or subsidiaries to be covered, if any.
Nature of
Name Location Relationship
Nature of SIC
Business Code
6. Coverages applied for:
Tailored Plans: [] Life [] AD&D
Small Group Trust Plans: []Life
Voluntary Plans: [] Voluntary Life
[]ACLI []STD []LTD ~Dental []FlexLTD []Other
[] AD&D [] STD [] LTD [] Dental
[] Voluntary LTD [] Voluntary Dental [] Voluntary STD
· 7..Requested effective date of insurance 10-01-03
8. Waiting period or service requirement (applies to all coverages unless otherwise stated):
Current employees 0 months Future employees 0 months
9. Entry date after becoming eligible (applies to all coverages unless otherwise stated):
r~ Immediate [] First of the month occurring on or after [] Other
NOTICE TO APPLICANTS
A. $ __ has been paid to be applied toward the first premium due for the coverage(s) elected by the applicant.
COVERAGE IS NOT EFFECTIVE UNTIL THIS APPLICATION IS APPROVED AND ACCEPTED BY THE GROUP
INSURANCE HEADQUARTERS OF FOP, TIS BENEFITS LOCATED IN KANSAS CITY, MISSOURI.
B. The applicant certifies that all information provided is correct and is bound by the terms and conditions of the group
policies.
C. Fortis Benefits will apportion experience refunds, if any, in accordance with its formula for calculating such refunds.
D. Tailored Plans: The group policy will be issued to the applicant, if approved. A final application will be executed
when the policy is delivered.
E. Small Group or Voluntary Trust Plans: This application is to participate in the Trust which holds the small group or
voluntary plan group policies.
F. ERISA- The coverage applied for provides benefits for the employee welfare benefit plan established and main-
tained by the employer under the Employee Retirement Income Security Act (ERISA), unless otherwise exempted
by law. The employer is the Plan Administrator unless otherwise noted.
G. Coverage will automatically terminate if the premiums are not paid before the end of the grace period following the
due date. Payment of premiums for coverage provided during the grace period is required.
H. All insurance coverage may be terminated if the number or percentage of participants falls below that required by
the policy.
I. No one except the President, Vice President, Secretary or Chief Financial Officer of Fortis Benefits can make, alter
or discharge contracts or waive any of Fortis Benefits' rights or requirements.
Fortis Benefits Insurance Company 2323 Grand Boulevard Kansas City Missouri 64108-2670
Telephone (816) 474-2345
Form I (12/98)
10. Contributions (applies to all coverages un/ess otherwise stated below--specifically note for DLI and Dental):
Total number of employees: Fulltime ~]R Parttime ]0]
Total number of participating employees: Full time 318 Part time 0
~ Non-contributory (Employer pays 100%) [] Contributory (Employee pays % of cost or $
Is participation in the Fortis coverage(s) mandatory? [] Yes ~ No
IsaSection 125 Plan in force? I~Yes []No
Is the Fortis coverage(s) contained in the Section 125 plan? ~ Yes [] No
supplement.
If"Yes," contributions are: [] Post-tax · ~ Pre-tax [] Post- or Pre-tax at individual election
If contributions are paid post-tax, please state the post-tax pementage of premium .
Comments
If "Yes," please attach Section 125
11. Employee Assistance Program (If elected, EAP form should be completed.): N/A
[] National Phone [] Local Phone [] In Person Assessment [] Short Term Counseling
12. Administration--Certificate face pages, billing, beneficiary changes to be prepared by:
A. [] Fortis Benefits Home Office Prepare bills by: [] Individual lists, or [] Summary
[] Policyholder * Initial bills to be prepared: [] Policyholder [] Fortis Benefits Home Office
[] Third Party Administrator (TPA must be approved by Home Office before submitting case and Appointment of
Administrator form must be sent in.)
Administrative Allowance is %.
· Any special Administrative instructions, and the correspondent's name and address are given below.
B. [] Special administrative or certificate instructions apply
[] Summary Plan Description (SPD) (Attach SPD Supplement if required.)
C. Mailing Instructions: Administrative Kit: [] Broker [] Policyholder
Booklet / Certificates: [] Broker [] Policyholder
Contract: [] Broker [] Policyholder
Initial Bill: [] Broker I~ Policyholder
[] Sales Office
[] Sales Office
[] Sales Office
E] Sales Office
13. Correspondent
A. Name&title: []Mr. :Ii. Ms. Yesenia Garza; Benef~t.~ P.c)n'~H'i~tn'r-
[] Correspondent is not an employee of the employer. Explain and give name and address. ("Appointment of
Correspondent Under Group Policy" form must accompany submision.
B. Renewal letters to be sent to:
~] Same as above, with ccFy to, brc, kc.;'
[] Broker, for delivery to'client
[] Other (Provide name, title and address.):
[]Mr. []Ms.
14. Premium mode: ~;~:Monthly [] Quarterly [] Semi-Annually [] Annually
Additional available options for voluntary coverages: [] Biweekly [] Semi-monthly EIWeekly
15. For groups of 450 or more lives, please list the locations by state and the number of employees employed in each state
below. (A breakdown by state is only needed if there are 50 or more employees in any one given state.)
16. Indicate contract issue state if not the state where the applicant's main office is located and an explanation of locations.
Form I (12/98)
17. Separate accounts: [] Yes ~] No
If "Yes," please give details. Include name and address.
(Each account must have a minimum of 10 employees.)
18. Are any eligible employees located outside the United States? [] Yes ~ No
If "Yes, "give name(s) of employee(s), location(s), and country(les) of citizenship. Also advise how long the individual(s)
will be located outside the U.S.
19. Experience refunds (applies to all coverages, unless otherwise stated in Remarks): .
Gt Standard 100% pooling' [] Special single.case experience refund
20. A. Do you currently have any group insurance coverage in force? [] Yes [] No
If"Yes," will you be terminating such coverage(s) as of the effective date of the Fortis Benefits coverage (if approved)?
[] Yes [] No
If"Yes," are you requesting transfer treatment? [] Yes (Please provide a copy of your in force contract.)
(For dental transfer, we will need the prior carrier bill.)
[] No (Please explain why.)
B. Are you currently making application for other group insurance programs?
If "Yes," please explain.
[] Yes [] No
21. Remarks (Identify by number.)
22. [] I certify that all employees are actively at work at their usual place of business today. -'
[] There are employees who are not actively at work at the usual place of business today. (Please complete the following.).
Name Date Last Worked Expected Date Return to Work Reason for Absence
Title City Manager
MUST BE AUTHORIZED REPRESENTATIVE OF POLICYHOLDER
Fortis Benefits representative
Rep Code
Bi 11 Ei sen
Date
(If application is signed after the effective
date, a No Claims letter must be attached.)
Date
(Please note in Remarks if there is more than one rep.) Sales Office.
Producer information:
1. Individual or firm (legal name)
Writing agent of firm.
Address..
City/State/ZIP
Phone no. . Fax no.
Payee no. Production Split__
License no.
Producer
signature Date
Commissions payable to: I-I Firm, or [] Individual
Commissions payable by: [] Assignment
[] Direction Method
2. Individual or firm (legal name)
Writing agent of firm
Address
City/State/ZIP
Phone no. Fax no.
Payee no. Production Split
License no.
Producer
signature Date
Commissions payable to: [] Firm, or [] Individual
Commissions payable by: [] Assignment
[] Direction Method
New Producers: Please attach a copy of your current state insurance license and signed producer contract.
NOTE: On Florida and California cases, Agents/Broker must note his/her license number for.contract state.
Form I (12/98) KC2933 (1111999)
City of Pearland
DENTAL DESCRIPTION OF BENEFITS
***Please take this information to your dentist***
Effective Date: 10/01/2003 Group Number: 1-744
CALENDAR YEAR DEDUCTIBLE (APPLIES'TO CLASS II &'Ill)
Individual $50
CALENDAR-Y-EARMAX~ML,ZM. BENEFIT (APPLIES To~CLASS*|,-ll&-III) .........
Each Eligible Family Member $1,500
ORTHODONTIA (APPLIES TO CHILD ONLY) I
Deductible $0
Lifetime Maximum $1,500
= CLASS I CLASS II ·CLASS III CLASS IV
· DIAGNOSTIC BASIC MAJOR
& PREVENTIVE RESTORATIVE RESTORATIVE ORTHODONTIA
Coinsurance: 100% 80% 50%** 50%**
Description Oral exams, Fillings, including Crowns, full and Orthodontic
of Services: cleanings, bitewing tooth-colored fillings partial dentures, extractions, full
X-rays, fluoride on posterior teeth, bridges, treatment or partial bands,
treatments, sealants, simple extractions, of TM J, implants, appliances
space maintainers, stainless steel Brite Solutions (removable and
intraoral complete crowns, root canal (includes tooth- fixed)
series X-rays or therapy, oral colored crowns on
panoramic film surgery, posterior teeth and
periodontics, general bleachingl, age
anesthesia and 16+)
intravenous
sedation, intraoral
and extraoral X-rays
** A 12-month wait for new hires only
No deductible, a 50% coinsurance rate, and a lifetime maximum of $500 apply to bleaching of teeth. Consult your tax
advisor regarding possible tax consequences.
Pre-Determination: If the charge for any dental treatment is expected to exceed $300, Fortis Benefits recommends a
dental treatment plan be submitted to claims for review before treatment begins.
LOCAL OFFICE:
CLAIMS/CUSTOMER SERVICE:
Fortis Benefits
Millenium Tower, 10375 Richmond Ave, Suite 1675
Houston, TX 77042
Phone: (713) 780-1111
FAX: (713) 780-2121
Fortis Benefits Insurance
PO Box 2940
Clinton, IA 52733
(800) 442-7742
Electronic Claims: Payor 70408
This sheet is intended as a summary of benefits for a non-voluntary dental plan. Please consult your certificate booklet
for complete coverage details.'
The Benefits Sol utio ns PeoplesM 03/19/2003 11:53:12 697915 1
MEMORANDUM
TO: Mayor and Councilmembers
FROM: Bill Eisen, City Manager l�
Mary Hickling, Director o Human Resources
DATE* July 22, 2003
SUBJECT: Cigna and Fortis Renewal Rates
After careful review of Cigna's proposed renewal rates for medical insurance, it is our
recommendation that we accept Cigna's proposed renewal rate of 11.7% increase.
Fortis Benefits Insurance Company submitted only one proposed rate for dental coverage.
After reviewing this proposal it is our recommendation that we accept the 3% increase
and renew our contract with Fortis to continue to provide dental coverage to our
employees.
If you have any questions or need additional information, please do not hesitate to contact
us.
3519 LIBERTY DRIVE • PEARLAND, TEXAS 77581-5416-19 • 281-652-1600 • www.ci.pearland.tx.us
Printed on Recycled Paper ter,
MEMORANDUM
TO: Bill Eisen, City Manager
Mary Hickling, Director of Human Resources
FROM: Yesenia Garza, Benefits Coordinator
DATE* July 17, 2003
SUBJECT: Dental Renewal Rates.
Fortis Benefits Insurance Company has submitted the renewal rates for our dental plan
for October 2003 (see attachment). There will be a 3% increase to our current rates and
the dental plan will remain the same. Fortis will also include a vision discount plan at no
additional cost to the City (see attachement).
•
3519 LIBERTY DRIVE • PEARLAND, TEXAS 77581-5416-19.281-652-1600 • www.ci.pearland.tx.us
Printed on Recycled Paper 0
July 9, 2003
Ms. Yesenia Garza
City of Pearland
3519 Liberty Drive
Pearland, TX 77581
RE: Renewal Effective 10/1/2003
Dear Yesenia.
• r .
♦ ■ . • ♦•
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it
FORTIS
Solid partners, flexible solutions'
At this time of your anniversary date, Fortis Benefits Insurance Company again would like to welcome you
as our customer. Our mission is to deliver high -quality products that build and strengthen employees'
loyalty, while providing security for them and their families
As part of our continuing effort to provide our customers with the best products and services, we will be
moving all of our dental customers from the Protective Life Insurance dental plan to Fortis Benefits new
Freedom Solutions plan. Specifically, the City of Pearland's employees will be moving from the Pro Two
Level TwoC to the Premier Dental Solutions — which is similar to your current plan of benefits In order to
provide coverage under the updated plan, it will be necessary to replace your current group policy;
however, your group policy number and customer service contacts will remain the same: For more details
concerning this change please refer to the enclosed attachment.
The new Fortis Benefits contract will be effective as of October 1, 2003. Enclosed is a copy of the new
Group Preliminary Application. To assure that the City of Pearland's group dental coverage is continued
with no lapse in coverage, you will need to complete and sign the enclosed application and return it to me
no later than September 1, 2003.
Listed below is a comparison of your current versus your renewal rates.
Indemnity
Employee Only
Employee + Spouse
Employee + Child(ren)
Employee + Family
Current
$27.00
$48.38
$62.67
$84.05
Renewal
$27.81
$49.83
$64.55
$86.57
Fortis Benefits is committed to providing the City of Pearland with the highest quality, affordable dental
cov rage available. We are The Benefits Solutions People! Please call me directly at 713-780-1111 Ext.
16 +ould you have any questions or concerns regarding any additional information.
Joan
Acco
sincerely,
cy
t Manager
Vision Discount Services
ACCESS PLAN
Your dental plan includes a vision discount plan through Vision Service Plan (VSP). The vision plan includes
discounts on exams and the purchase of eyeglasses, contact lenses, sunglasses and other prescription eyewear
when provided by VSP doctors. VSP is available for you and everyone covered on your dental plan!
Services Available from a VSP Doctor
• Eye Exams — 20% discount applied to VSP doctor's
usual and customary fees for eye examsl
• Glasses — 20% discount applied to VSP doctor's usual
and customary fees for complete pairs of prescription
glasses and spectacle lens options2
• Contact Lenses -15% discount on
doctor's professional services when purchasing all
prescription contact lenses2 (materials at doctor's
usual and customary fees)3
• Laser VisionCareS "1-- VSP has contracted with many
of the nation's laser surgery facilities and doctors,
offering you a discount off PRK and LASIK surgeries,
available through contracted laser centers
Other Valuable Features for You
• Immediate savings when using a VSP
doctor
• You may use the discounts as often as
you wish
• No waiting periods
• No deductibles
• No claim forms to fill out
How to Use VSP
Locate a VSP doctor near you. You may either use our Web -based doctor locator at www.vsp.com, or call
VSP at 1-800-877-7195 to request a doctor listing.
Identify yourself as a VSP member and be prepared to provide the covered member's social security number
when you make your appointment. (The VSP doctor will verify your eligibility and vision plan coverage,
and will obtain authorization for services and materials If you are not currently eligible for services, the
VSP doctor is responsible for communicating this to you.)
Your fees are automatically reduced at the time of service — with no claim forms to fill out!
THIS VISION DISCOUNT PLAN IS NOT INSURANCE.
1Note. Does not apply to contact lens services. See contact lens section for applicable discount.
2Discounts only offered through the VSP doctor who provided an eye exam within the last 12 months.
3VSP offers valuable savings on annual supplies of selected brands of contact lenses
VSP Member Services Support: 1-800-877-7195
Visit our Web site at www.vsn.com