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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.