HomeMy Public PortalAboutFlorida Blue Health Ins- Cancellation of PolicyCITY OF CRESTVIEW
OFFICE OF THE CITY CLERK
P. O. DRAWER 1209, CRESTVIEW, FLORIDA 32536
PHONE # (850) 682-1560 FAX # (850) 682-8077
September 1, 2015
Gwen Johnson -Hilliard
Florida Blue
2190 Airport Blvd, Suite 390
Pensacola, FL 32504
RE: City of Crestview, Group #59530
Dear Gwen,
Please allow this letter to serve as notice to terminate the City of Crestview Health Insurance Policy,
Group #59530, effective October 1, 2015.
Thank you and your team for the service you have provided. We appreciate your dedication.
Sincerely,
A
Elizabeth Roy City
Clerk
cc: Glenn Little Elizabeth
Penfield
Employer Application fo. _arge Group
Groups with 51 or more Eligible Employees
To avoid processing delays, please make sure you:
1. Answer all questions completely and accurately.
2. DO NOT CANCEL YOUR EXISTING COVERAGE UNTIL YOU RECEIVE WRITTEN NOTIFICATION OF APPROVAL
3. Include a deposit check in the amount of any required premiums; such amount will be returned in the event coverage does not become effective and will be
applied against the first month's premium if coverage does become effective.
General Information
Group's/Company's Legal Name
City of Crestview
UnitedHealthcare
Requested Effective Date 10-01-2015
Group Name to appear on ID card (maximum 30 characters)
Cl 11 TI YI 101 F1 1 Cl RI El SI TLV_L_I1 ELW
I
I
1
I
Street Address
198 NORTH WILSON STREET
Tax ID
59-6000295
City
CRESTVIEW
State
FL
Zip Code
32536
Names of Owners/Partners (if applicable)
Internet Access?
®Yes ❑No
Contact Person
ELIZABETH ROY, CITY CLERK
Email Address
elizabethroy@cityofcrestview.org
# of Years
in Business
99
Billing Address (if different)
PO BOX 1209, Crestview, Florida 32536
Telephone
(850) 682-1560
Fax
Multi -location group/company?*
❑ Yes X No
# of Locations
1
Address (es) (or list on additional sheet of paper)
Organization Type ❑ Partnership ❑ C-Corp ❑ S-Corp ❑ LLC/LLP
❑ Sole Proprietor X Other Municipality
Nature of Business
CITY GOVERNMENT
Industry Code
9111
Waiting Period ❑ 1st of Policy Month following Date of Hire
for new hires X 1st of Policy Month following 60 ❑ months ® days of employment
❑ Date of Hire (no waiting period)***
❑ _ ❑ months ❑ days of employment following Date of Hire***
Waiting Period waived
for initial enrollees
❑ Yes X No
Medical Benefit Plan Option
X Calendar Year
❑ Policy Year***
Number of Persons currently on COBRA/Continuation
and/or Short/Long Term Disability
(employees/dependents) O
Number of Employees Termed
in last 12 Months
45
Classes Excluded: X None ❑ Union ❑ Hourly
❑Non -Management ❑Salary
Have Workers' Comp?
XYes ONo
Name of Workers' Compensation Carrier
FLORIDA LEAGUE OF CITIES
Domestic Partner Coverage?
XYes ❑No
Names of Owners/Partners not covered by Workers' Compensation
❑ By checking this box,1 acknowledge that I do NOT want UnitedHealthcare to act as my COBRA or state continuation of coverage administrator.
*If the majority of your employees are not located in your state of application, UnitedHealthcare policies and/or state law may require that your policy be
written out of a different state and/or that your benefit plans vary.
Partici ation
p
# Employees
Applying for:
# Employees
Waiving for:
Contribution
Medical
Employer
%
Employer
%for Dep
# Eligible Employees
I Ineligible Employees
Total # Employees
I Hours per week
to be eligible 30
198
Medical
185
Medical
13
Emp 100%
50°10
5
Dental
Dental
Dental
203
Vision
Vision
Vision
for
from
Basic EE Life/AD&D
Basic EE Life/AD&D
Basic EE Life/AD&D
c '�
Basic Dep Life
Basic Dep Life
Basic Dep Life
# Hours per week to be eligible
Disability coverage if different
above**
Supp EE Life/AD&D
Supp EE Life/AD&D
Supp EE Life/AD&D
=,
Supp Dep Life/AD&D
Supp Dep Life/AD&D
Supp Dep Life/AD&D
STD
STD
STD
4
**For Disability products the
minimum # of work hours per
week to be eligible is 30 hours.
***Not applicable to NHP
****Only available to Groups with
100+ Eligible Employees
STD Buy Up****
STD Buy Up****
STD Buy Up****
LTD
LTD
LTD`'
LTD Buy Up****
LTD Buy Up,***
LTD Buy Up ****`
Other
Other
Other
Note: Life insurance premiums for totally disabled insured are waived for 6 months.
❑ Yes ❑ No Acceptance of this application will replace existing life insurance coverage.
Coverage provided by "UnitedHealthcare and Affiliates":
Medical coverage provided by UnitedHealthcare Insurance Company, UnitedHealthcare of Florida, Inc., Neighborhood Health Partnership, Inc or All Savers Insurance Company
Dental coverage provided by UnitedHealthcare Insurance Company
Life, Short -Term Disability (STD) and Long -Term Disability (LTD) Insurance coverage provided by UnitedHealthcare Insurance Company
Vision coverage provided by UnitedHealthcare Insurance Company
LG.ER.I3.FL 10/13 page 1 of 5
213.6206 11/13
Gbneral Information (continued)
Enter the Prior
Calendar Year
Average Total
Number of
Employees
219
Note: Only applies to
groups with less than
100 Eligible Employees
Under Health Care Reform law, the number of employees means the average number of employees employed by the company during
the preceding calendar year. An employee is typically any person for which the company issues a W-2, regardless of full-time, part-
time or seasonal status or whether or not they have medical coverage.
To calculate the annual average, add all the monthly employee totals together, then divide by the number of months you were in
business last year (usually 12 months). When calculating the average, consider all months of the previous calendar year regardless of
whether you had coverage with us, had coverage with a previous carrier or were in business but did not offer coverage. Use the
number of employees at the end of the month as the 'monthly value" to calculate the year average. If you are a newly formed business,
calculate your prior year average using only those months that you were in business. Use whole numbers only (no decimals, fractions
or ranges).
❑ Yes ® No
Are there any other entities associated with this group that are eligible to file a combined tax return under Section 414 of the Internal
Revenue Code? If yes, please give the legal names of all other corporations and the number of employees employed by each. Note: If
you answered yes, this answer impacts your answers to the other questions regarding group size.
❑ Yes ® No
Subject to ERISA?
If No, please indicate appropriate category:
❑ Church ❑ Federal Government
❑ Indian Tribe — Commercial Business ® Non -Federal Government (State, Local or Tribal Gov.)
❑ Foreign Government/Foreign Embassy ❑ Non-ERISA Other
❑ Yes
No In the past 36 months, has the Group/Company or any affiliated entity filed for protection or operated under federal/state bankruptcy
laws? (Chapter 7 or 11)
❑ Yes ® No
In the past 36 months, has any creditor filed or threatened to file a petition requesting the Group/Company or any affiliated entity be
placed voluntarily into bankruptcy?
❑ Yes ® No
Does your group sponsor a plan that covers employees of more than one employer?
If you answered Yes, then indicate which of the following most closely describes your plan:
❑ Professional Employer Organization (PEO) ❑ Multiple Employer Welfare Arrangement (MEWA)
❑ Taft Hartley Union ❑ Governmental
❑ Church ❑ Employer Association
❑ Yes ® No
Is your group a Professional Employer Organization (PEO) or Employee Leasing Company (ELC), or other such entity
that is a co -employer with your client(s) or client -site employee(s)?
If you answered Yes, then by signing this application you agree with the certification in this section.
I hereby certify that my company is a PEO, ELC or other such entity and that only those employees that are the corporate employees of
my company, and not my co -employees, are permitted to enroll in this group policy. If my group at any point after I sign this application
determines that the group will provide coverage to the co -employees under the group's plan, I understand that UnitedHealthcare will
not cover the co -employees under this group policy.
❑ Yes ® No
Do you currently utilize the services of a Professional Employer Organization (PEO) or Employee Leasing Company (ELC), Staff Leasing
Company, HR Outsourcing Organization (HRO), or Administrative Services Organization (ASO)?
Do you continue medical coverage during a leave of absence (not including state continuation or COBRA coverage), and if so, for how long once an
employee begins a leave of absence?
(Please refer to the applicable state and federal rules that may require benefits to be provided for a specific length of time while an employee is on leave.)
❑ Last Day worked (following the last day worked for the minimum hours required to be eligible)
❑ 3 Months (following the last day worked for the minimum hours required to be eligible)
❑ 6 Months (following the last day worked for the minimum hours required to be eligible)
® UnitedHealthcare Policy Special Provisions Related to Medical Eligibility*
❑ No, we do not offer medical coverage during a leave of absence
*UnitedHealthcare Special Provisions Related to Medical Eligibility Note: This does not apply to NHP.
If the employer continues to pay required medical premiums and continues participating under the medical policy, the covered person's coverage will remain
in force for: (1) No longer than 3 consecutive months if the employee is: temporarily laid -off; in part time status; or on an employer approved leave of absence.
(2) No longer than 6 consecutive months if the employee is totally disabled.
If this coverage terminates, the employee may exercise the rights under any applicable Continuation of Medical Coverage provision or the Conversion of
Medical Benefits provision described in the Certificate of Coverage.
page 2 of 5
ktRA and Supplemental Insurance Information
Do you currently offer or intend to offer a Health Reimbursement Account (HRA) plan and/or comprehensive supplemental insurance policy or funding
arrangement in addition to this UnitedHealthcare medical plan?
Answers must be accurate whether purchased from UnitedHealthcare or any other insurer or third party administrator.
HRA ❑ Yes ® No
If yes, please identify type: ❑ UnitedHealthcare HRA (any HRA design offered through UnitedHealthcare) ❑ Other Administrator HRA
HRA plans administered by other insurers or third party administrators must comply with UnitedHealthcare HRA design standards.
Comprehensive Supplemental Insurance Policy or Funding Arrangement ❑ Yes ❑ No
If you answered "Yes" to either question above, you must choose from the list of UnitedHealthcare HRA-eligible medical plans as shown to you by your broker
or agent. Other plans are not eligible for pairing with these arrangements. Purchase of such arrangements at any point during the duration of this policy will
require you to notify UnitedHealthcare,
HRA/HSA Employer Premium Contribution
Option #1
Option #2
Option #3
Medical Plan
03559
05770
HMO 059
Employee
572.82
573.24
543.28
Employee + Spouse
1,271.67
1,205.99
1,206.09
Employee + Child(ren)
1,042.53
988.69
988.77
Family
1,758.57
1,667.74
1,667.87
HRA/HSA Employer Account Funding Amount
N/A
Employee
Employee + Spouse
Employee + Child(ren)
Family
HRA/ HSA Account Administrator:
Are there any other contributions or benefit reimbursements allowed? ❑ Yes ® No
Who will provide account balances to UnitedHealthcare?
Current Carrier Information
Does the group currently have any coverage with UnitedHealthcare or has the group had any UnitedHealthcare coverage in the last 12 months?
❑ Yes No If Yes, please provide policy number and Coverage Begin Date /_/_ End Date /_/_
Has this group been covered for major dental services for the previous 12 consecutive months? ❑ Yes ❑ No
Name of Carrier
Coverage Begin Date
Coverage End Date
Current Medical Carrier
❑ None
Florida Blue
10/m /11
09/30/15
Current Dental Carrier
❑ None
Current Life Carrier
❑ None
Current Disability Carrier
❑ None
page 3 of 5
Disclosures
N you are applying for medical coverage, please answer the following questions to the best of your knowledge by referencing available employee records and other
personnel documents for all eligible employees and dependents (proprietors, partners, corporate officers, employees, spouses, and dependent children) to the extent
permitted by applicable law. UnitedHealthcare is only seeking to collect information about the current health status of those employees and their dependents who are
applying for coverage. In answering these questions, do not include any genetic information about your employees or their dependents, including requests for genetic
services, genetic diseases for which they may be at risk or family medical history information.
Please provide details to "Yes" answers in the space provided.
IMPORTANT: Your answers to these questions must include all COBRA and State Continued individuals covered by your present plan.
❑ Yes No 1. Within the past 3 years, has any employee or dependent filed a claim for short-term disability, long term disability, social security
disability income, workers' compensation, Medicare, or Medicaid benefits or any other type of disability benefits on any policy?
❑ Yes No 2. During the past 3 years, has any employee or dependent had life, disability or health insurance declined, postponed, changed,
cancelled or withdrawn?
❑ Yes ® No 3. Except for a maternity or paternity leave, within the past 3 years, has any employee applied for a family or medical leave of more than
2 weeks due to injury, disability or illness of the employee or dependent?
❑ Yes X No 4. Within the past 3 years, has any employee been absent from work for more than 2 consecutive weeks due to injury, disability or illness?
❑ Yes X No 5. Except for a mental health admission, during the past 3 years, has any employee or dependent had a hospital stay lasting more than
5 days or is any employee or dependent contemplating treatment that would require hospitalization for more than 5 days?
Yes ® No 6. Is any employee or dependent currently hospitalized?
❑ Yes X No 7. Within the past 3 years has any employee or dependent been diagnosed by, treated by, or received prescription medication from a
licensed member of the medical profession for any of the following conditions?
❑ Cancer (any type)
❑ Lung disease or respiratory problem (any type)
❑ Heart disease or disorder (any type)
❑ Organ, tissue or cell transplant
❑ Liver disease (any type)
❑ Kidney disease (any type)
❑ Pancreatic disorder (any type)
❑ Diabetes
❑ Hepatitis
❑ Morbid obesity
Congenital abnormality
❑ Vascular disease (any type)
❑ Neurological disorder (any type)
• Immunological disorder (reportable types)
❑ Alcohol or drug addiction or abuse
❑ Hemophilia or Blood disorder (any type)
H you have answered "Yes" to any of the questions above, please provide the requested information on the next page for each individual. If necessary, use additional
sheets of paper.
Additional information is not required for conditions related to HIV/AIDS/ARC.
Disclosures
Question
Number
(continued)
Check
Employee
One
Dependent
Age
Date of
Recovery
Date of Treatment/
Condition
Nature of
Medication
Name of
Condition
$ Amount
of Claims
Current
Treatment
page 4 of 5
Important Information
The Group/Company certifies that the information provided above is complete and accurate. The Group/Company shall notify UnitedHealthcare and Affiliates
promptly of any changes in this information that may affect the eligibility of employees or their dependents, including the addition of any newly eligible
employees or dependents. Prior to receiving notification of approval, the Group/Company shall notify UnitedHealthcare and Affiliates promptly of any significant
changes in the health status of an eligible employee or dependent including any inpatient hospital admissions. UnitedHealthcare and Affiliates shall be entitled
to rely on the most current information in its possession regarding the eligibility and health status of employees and their dependents in providing coverage
under the policy/policies for which application is being made.
I represent to the best of my knowledge the information I have furnished is accurate, and includes any employees and dependents who have elected
continuation of insurance benefits.
I understand that the Certificate of Coverage or Summary Plan Description and other documents, notices and communications regarding the benefit plan(s)
indicated herein on this Application may be transmitted electronically to me and to the Group's/Company's employees.
Upon receipt by UnitedHealthcare and Affiliates of this signed employer application and payment of the required policy charges, the group policy is deemed
executed. The deposit check in the estimated amount of the first month's premium is not considered payment of the required policy charges.
UnitedHealthcare disclosure regarding producer compensation:
In some instances, we pay brokers and agents (referred to collectively as 'producers") compensation for their services in connection with the sale of our
products, in compliance with applicable law. In certain states, we may pay "base commissions" based on factors such as product type, amount of premium,
group/company size and number of employees. These commissions, if applicable, are reflected in the premium rate. In addition, we may pay bonuses pursuant
to programs established to encourage the introduction of new products and provide incentives to achieve production targets, persistency levels, growth goals
or other objectives. Bonus expenses are not directly reflected in the premium rate but are included as part of the general administrative expenses. Please
note we also make payments from time to time to producers for services other than those relating to the sale of policies (for example, compensation for
services as a general agent or as a consultant).
Producer compensation may be subject to disclosure on Schedule A of the ERISA Form 5500 for customers governed by ERISA. We provide Schedule A
reports to our customers as required by applicable federal law. For specific information about the compensation payable with respect to your particular
policy, please contact your producer.
Any person who knowingly and 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.
Group/Company Signature / Date q' -3 Tide City Clerk
DO NOT CANCEL YOUR EXISTING COVERAUNTIL YOU RECEIVE WRITTEN NOTIFICATION OF APPROVAL
Producer Information (if applicable)
Producer Name
James Glenn Little
Agency
Barnes Insurance
Agent CodelTax ID Number
33-1106816
tur ��"""'-'"`" "�"•
'%tin Little � �=F"
S:77:,�m
Email Address
glittle@biafs.com
Social Security #
Phone Number
(850) 473-1500
Date
07/08/15
Florida License IDS
D004143
❑ Yes ❑ No To the best of my knowledge, acceptance of this application will replace
existing life insurance coverage.
All Payments to:
Barnes Insurance and Financial Services
Producer Commission Schedule (if applicable) Std Scale of 1.25 %
Street Address
1582 Airport Blvd
City
Pensacola
State
FL
Zip Code
32504
Rep Name
Rep
General Agent Information
General Agent
Phone k
Franchise Code
Street Address
City
State
Zip Code
page 5 of 5
rev 8-16-13
BILLING AND COLLECTION AGREEMENT
This Billing among United HeabhCnreServicem. Inc., and its subsidiaries
and affiliates (collectively ^UHS^). the designated service provider(s) (individually and collectively, "Service Provider')
Indicated onthe attached Exhibit 1 hothis Agreement ("Exhibit 1^). and the City ofCrestview ("Customer"), sets forth the
hemno and conditions under which UHG will eooimt in the billing and collection of Service Fsom from Cuotomer, and the
processing and remittance of the Gsn/ioe Fees to Service Provider. This Agreement is effective as of 10/01/2015 (the
"Effective Date").
RECITAL
Customer has purchased certain medical insurance products ("N1mdica|Benefit Phan(s)~)from acompany controlled byor
under common control with UHS including, without limitation, UnftedHealthcare Insurance Company (each, an "Affiliate").
Customer and Service Provider represent that they have entered into one or more valid agreements under which Service
Provider agrees to provide services to oeaiat Customer with its benefit plan (individually and collectively, "Service
Agreement") in return for agreed upon compensation to be paid by Customer ("Service Fee").
Customer and Service Provider acknowledge that UHS isnot aparty bothe Service Agreement.
Customer and Service Provider have requested that UHG bill Customer for the monthly Service Fee on the Service
Provider's beholf, and incorporate the Service Fee bill into the Medical Benefit Plan(s) bill for the Customer's
administrative ease.
Customer, Service Provider, and UHS acknowledge and agree that the Service Fee is not part of the premium charged for
any Medical Benefit Plan offered by an Affiliate and is not a required contingency of obtaining the coverage purchased by
Customer.
UHS agrees to provide the billing menioae described herein in reliance upon and subject hothe aforementioned recitals
and terms and conditions set forth below.
TERMS AND CONDITIONS
Section1: Rights and Responsibilities.
A. Responsibility mfUHS;
1. UHG agrees to bill Customer for the Gonica Fee identified in Exhibit 1 on o monthly basis and incorporate this
billing with the premium bill for the Medical Benefit Plan(s) purchased by the Customer during the Term.
2. UHG agrees toforward nrtransmit any collected Gmmioe Fee to the appropriate Service Provider (au outlined in
Exhibit 1)within GOdays ofreceipt ofthe Service Fee from Customer.
B. Responsibilities of Customer:
1. Customer agrees to pay the Service Fee at the oanna time as payment is mode for the premium for the yNodiva|
Benefit Plan(e)included onthe same invoice.
2. Customer agrees to notifyUHSimmediately ofthe termination ofany one ormore Service Agreement.
3. Customer shall bska all steps necessary to recover from Service Provider any overpayment of the Service Fee
which in due to Customer's error.
4. Customer agrees that it is responsible for any ban reporting na|ob»d to the payment of the Service Fee to the
Service Provider.
C. Responsibilities of Service Provider:
1. Service Provider agrees to notify UHG immediately ofany change in the contractual relationship between it and
the Customer that would impact the Service Fee payment.
2. Service Provider agrees to return to UH8 any Service Fee overpayments that occur as a result of processing
error byUH8within thirty (3O)days ofUH8'mrequest for such repayment.
3. Service Provider agrees that UH8 is not responsible for any tax reporting related to the payment of the Gan/ioo
Fee hothe Service Provider.
4. Service Provider acknowledges and agrees that it is solely responsible for determining what licenses (state, local
or otherwise) are required for it to perform the services described herein and/or in the Service Agreement, and for
obtaining such licenses and maintaining them in good standing throughout the Term.
Section 2: Payments and Adjustments.
A. All parties agree to promptly notify the others upon becoming aware of an incorrect payment amount, and to
promptly remit any amounts overpaid.
B. If the amount Customer pays to UHS for both Service Fee and premium related to the Medical Benefit Plan(s)
purchased by Customer is less than the amount billed by UHS, the amount forwarded to the Service Provider will
vary in direct proportion to the difference in the amount paid compared to the amount billed. This variation will
apply regardless of the basis used for calculating the Service Fee, including a percent of premium, a set amount
per enrolled employee, per month, or a set dollar amount per month.
C. UHS may recover overpayments from Service Provider by offsetting the overpayment against any other
compensation due to Service Provider by UHS.
D. Service Fees will be subject to garnishments and any other legal attachments as required by a legal court order or
similar action.
E. The Service Fee amount may be modified on a prospective basis only. UHS must be informed of the change in
writing, including the date that the change will be implemented (which must be at least 30 days from the date of
such notice to UHS). UHS will notify Customer and Service Provider in writing that it will implement the change
on the date requested; provided, however, that UHS has the right to designate a date subsequent to the date
requested if, in its reasonable judgment, UHS believes that such a delay is necessary.
Section 3: Amendments.
A. UHS may amend the terms and conditions of this Agreement, except for terms and conditions related to the
amount of the Service Fee, at any time by notifying Customer and Service Provider of the change in writing at
least 30 days prior to the effective date of the change.
B. Customer may request a change to the amount of the Service Fee subject to the requirements contained in
Section 2(E) above.
C. All other amendments to the provisions of this Agreement, not addressed by 3(A) or 3(B) above, must be set forth
in writing and signed by an authorized representative of each party to this Agreement.
Section 4: Term and Termination.
This Agreement is effective on the Effective Date and shall continue until terminated as set forth in this Section 4 (the
"Term").
A. Customer may terminate this Agreement at any time, for any reason (or no reason), by providing written notice of
such termination; provided, however, that if the termination does not specify a future effective date, Customer
acknowledges and agrees that such termination will be effective the first of the month following UHS's receipt of
such notice. Unless otherwise specifically so stated, notice that the Customer has elected to work with a different
Service Provider shall be considered to be effective notice of the termination of this Agreement.
B. UHS and Service Provider may terminate this Agreement at any time, for any reason (or no reason), by providing
written notice of such termination at least 60 or more days before the effective date of the termination.
C. UHS may terminate this Agreement immediately, upon written notice to Customer and Service Provider, if UHS is
made aware that responsibilities and duties called for herein are no longer legally permissible.
D. This Agreement will terminate automatically and without any further action being required on the part of any party
as of the effective date of the cancelation or termination of the last of the Medical Benefit Plan(s) purchased by
Customer from an Affiliate then in existence.
E. In addition, this Agreement will terminate automatically and without any further action being required on the part of
any party as of the effective date of a subsequently executed Billing and Collection Agreement by and between
UHS, Customer and any service provider (whether the same Service Provider named in Exhibit 1 or not).
F. Notwithstanding the foregoing, the provisions of this Agreement which, by their nature, are intended to survive
beyond the termination of this Agreement shall survive such termination, including, but not limited to, Sections
1(B), 1(C), 2(A), 2(C), 2(D), and 5.
Section 5: Additional Customer and Service Provider Acknowledgments and Approvals.
A. Customer understands that UHS may compensate Service Provider for the sale, service and retention of Medical
Benefit Plans and that the Medical Benefit Plan(s) purchased by Customer may, if eligible, be taken into account
in the calculation of any bonus or override program offered by UHS to Service Provider. Eligibility for such bonus
and/or override programs is determined by UHS based on a number of factors including, but not limited to, state -
specific regulatory requirements.
B. By executing this Agreement below, Customer represents that either the payment of a bonus and/or override by
UHS, as described in 5(A) above, does not create a conflict of interest or, to the extent of any apparent conflict, it
is understood and hereby waived by Customer.
C. Customer and Service Provider acknowledge and agree that the Service Fee may be deposited by UHS in an
account with other funds collected by UHS in the normal course of business. All available funds may be invested
in short-term Instrumente sifbrtiY-etter depOilt into this account-. (typically once per dily) which dineern interest
income at market rates. 'By Way Of exeMPle Only, fiiR tipPticeble SecOnd quarter, 2013 market Inter Si OtieS Were
0.23% in April, 0.22% ih luny, end juneywhrCh is feitty, standard for market • relation fd
utilization fot such shortterrn Invisitrnenti,..Stifylde Feet enelenersilly treated like all other fonds et:41440d by
UHS in the normal cbUtie of b4sIneis 0.16000i ii1-.:UHS'i'pOestiisiOn., Service Fees are iii UHS,1,1 POSgeg816n.fbt
a period Of epproxinietely 30 fo ileysi;bnartibtiniii.dircuinetenees prior to being forwarded' to the Sei'vice
Provider is discussed eieevitieti in Olt Agreement, ;Tile Payet.Of illy interest received by UHS On Service Fees -
as the result of stich, Shbrt-tettrf eatiiitY 'Iwilt-be the' sponsor Of the relevant investment. vehicle. - UHS,.
reteint interest earned On the derviOd Kees While In froiseislion as consideration fot UHS's services under this
- - Agreement. , •
• „ - • -
D. Service PtoVider ackcnoWledOOS t tiit ift4Slies no'obligetions to Service Provider to collect amounts owed to it by
Customer other theihthOte e4reisily set iOrtfi In this Agreement. ,
E. Thit Agreement rePteeints the. enIlre Underiterldrng end agreement between the parties with respect to the
subjebt Meet addreiied hetein and .entireW end tOMpletely supersedes, voids and replaces all agreements,
negotiations, underetendingS einereprOlferittitibtii(Whether written or oral) in existence between the parties as of
the Effective, Date and'reliatiit to the, subject Metter:
F. This Agreemern rney be-exeduted in Cdunterparti, each of which shall be deemed to be an original, but all of
which, taken together,, Shall ,eibtlatItute one end the tame Agieernent. A signature by facsimile transmission or
other eleCtridnic means-.)4/hiCh alloWs the identity of the signer to be reasonably confirmed shall be as good and
binding as an original signatrie .
Signatures: Thribugh the signature of their respective authorized representatives, the parties hereby agree to the terms and
conditiOns of this Agreement.
For Cuttomer: -Or Service Provider:
Signature- of Customer
Signature
Elizabeth Roy James Glenn Little
City Clerk
Title
Printed Name
SSAVT1N
09/03/2015 Vice President
For UHS:
Date Title
09/04/2015
Date
For Service Provider (if more than one):
Signature —Authorized Representative
Signature
Printed Name
Pnnted Name
Title
SSNTTIN
Date
Title
Date
rev 1-29-13
BILLING AND COLLECTION AGREEMENT
EXHIBIT 1
This Sectior To Be Completed By Customer
Customer Name: The City of Crestview
Service Agreement Effective bate: 10/01/2015
besianatiorl_af Serv(ca.litovideits): Note: if miloti char ttMo Nice' PrOldeii a
relevant informatlon.for additional Service Providers on such additional Exhibittt:
Designated tervice Provider
(Person or firm that will receive Service Fee):
(Barnes Insurance 8 Financial Services
[
Complete two version., a Exhibit 1 and provide
Designated Service Provider,, .
(Pirsi'sii or firm that will receivb Service Fee):
I
vIce Provider Representative Responsible fbr Customer'i Account: Service Provider Representative Responsible for Customer's Account:
mes Glenn Little j [
Service Provider Address:
[1582 Airport Blvd, Pensacola, FL 32504 ] [
Service Provider Address:
]
I
PLEASE NOTE THAT THE INFORMATION CONTAINED IN THE BOX ABOVE MAY BE CHANGED PERIODICALLY BY UHS AS DIRECTED. ANY OTHER
ALTERATIONS TO THE TOP HALF OF THIS FORM MUST BE INITIALED BY THE CUSTOMER TO DOCUMENT CONSENT TO THE CHANGE.
Please check only one of the following Service Fee payment methods and indicate the TOTAL rate to be paid.
[X] Percentage of Medical Premium [_-1.25 ] % This option is not available for Ohio policies (use PEPM).
(Please be advised that, unlike commissions, the Service Fee is not a component of premium.)
Ll Per Employee Per Month (PEPM) $ [ 1.00
IF MORE THAN ONE SERVICE PROVIDER IS LISTED ABOVE, PLEASE INDICATE WITH SPECIFICITY HOW THE TOTAL FEE SHOULD BE DIVIDED
BETWEEN THE SERVICE PROVIDERS:
[X] Check here if the Designated Service Provider and Service Provider Representative named above are to be designated as the Agent of Record and Writing
Agent, respectively, of all of the Customer's non -medical lines of coverage. Checking this box will replace the existing Agent of Record and Writing Agent
for those lines of coverage. If more than one Service Provider is designated above, please indicate with specificity which, if any, non -medical lines of
coverage should have changes to the currently designated Agent of Record:
Signature (Authorized Representative of Customer):
Name (Printed) [ Fit'bek K 71 Title Phone [ sscrpZ 1U4�
For Internal Use Only (To he Completed By United Heal Care Services, Inc.)
UNET / BASICs Platform:
Payee / Producer ID:
WA CRID:
*Please use "AII" or list policies / state(s) covered by this speck agreement.
Policy*: *
Base / Situs State:
Customer #: Agreement State*:
J
Oxford / Pulse Platform:
Payee Code:
WA Code: :
FACETS Platform (RV/NHP):
Payee CRID:
Arrangement ID*:
Group #:
Base / Situs State:
Base / Situs State:
Agreement State:
West Coast / Nice Platform: (Requests for multiple payees and the amount to be paid to each should be listed out and attached)
Payee ID # Payee Name
Writing Agent ID# Writing Agent Name
All Group #s Covered by Agreement*:
*Please circle the group*that the service fee will be billed to.