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Resolution No. 94971 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 RESOLUTION NO. 9497 A RESOLUTION OF THE CITY COUNCIL OF THE CITY OF VERNON APPROVING AND RATIFYING THE ACTIONS TAKEN REGARDING THE PURCHASE OF HEALTH, DENTAL AND LIFE BENEFITS AND AUTHORIZING THE CITY TO DO ALL ACTIONS DEEMED NECESSARY OR ADVISABLE CONCERNING THE HEALTH, DENTAL AND LIFE BENEFITS WHEREAS, the City of Vernon has established a health care benefit plan or a health care benefit plan and trust to provide disability and/or medical care benefits for certain eligible persons; and WHEREAS, the City of Vernon has agreements with United of Omaha Life Insurance Company ("Omaha") for administering the City's employee health care plan and has agreements with Health Net of California, Inc. ("Health Net") for administering the City's HMO employee health care coverage; and WHEREAS, effective January 1, 2008, Omaha announced that it would not be renewing group health clients outside of Nebraska and Iowa; and WHEREAS, on October 23, 2007, the City Council of the City of Vernon concurred with the Risk Manager's recommendation to pursue medical coverage under Aetna Health of California, Inca ("Aetna"), dental coverage under Metropolitan Life Insurance Company ("MetLife") and group life coverage under Mutual of Omaha ("Omaha") for the period of January 1, 2008 through December 31, 2008 through the City's broker, Arthur J. Gallagher & Co.; and WHEREAS, in order to meet the urgent need for the health, dental and life benefits to be in place by January 1, 2008, the Risk 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 Manager submitted the necessary applications, subject to ratification by the City Council; and WHEREAS, the City Council of the City of Vernon desires to ratify the actions taken to obtain the necessary health and dental benefit coverage with Aetna and MetLife, to renew the life benefit coverage with Omaha, and to pay the following approximate yearly premiums: $382,992.00 for dental, $3,351,648.00 for health and $13,000.00 for life (Basic Life-$0.135 per $1,000 benefit; Basic AD&D- $0.04 per $1,000 benefit; Dependent Life-$0.38 per dependent unit of Spouse and/or Children); and WHEREAS, the City Council of the City of Vernon has determined that, pursuant to the provisions of subsection (a) of Section 2.27 of the Vernon City Code, it is in the public interest and necessity to ratify the actions taken in obtaining health benefits with Aetna, dental benefits with MetLife and life benefits with Omaha. NOW, THEREFORE, BE IT RESOLVED BY THE CITY COUNCIL OF THE ICITY OF VERNON AS FOLLOWS: SECTION 1: The City Council of the City of Vernon hereby finds and determines that the recitals contained hereinabove are true and correct. SECTION 2:. The City Council of the City of Vernon hereby approves and ratifies the applications submitted to Aetna and MetLife for health and dental care benefits for eligible persons and hereby approves and ratifies the renewal of life benefits for eligible persons with Omaha, a copy of the applications with Aetna and MetLife are attached hereto as, Exhibit A and incorporated by reference. SECTION 3: The City Council of the City of Vernon hereby authorizes the City Administrator, or his designee, to execute any and - 2 - 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 all documents necessary, especially any administrative services contracts or other health plan documents, for the purpose of securing the health, dental and life benefits and to implement and carry out the purposes of this Resolution on behalf of the City of Vernon. SECTION 4: The City Council of the City of Vernon hereby approves, ratifies and/or authorizes the payment of the annual premiums for health, dental and life benefits in accordance with the terms of the insurance purchased and/or renewed in an estimated not to exceed amount of $3,747,640.00. SECTION 5: The City Council of the City of Vernon hereby �Idirects the City Clerk, or her designee, to send a copy of this IlResolution to: Arthur J. Gallagher & Co. Gallagher Benefit Services, Inc. Attn. Brenda Lee, Area Assistant Vice President 505 N. Brand Blvd. 6th Floor Glendale, CA 91203-3944 SECTION 6: The City Clerk of the City of Vernon shall certify to the passage of this resolution, and thereupon and thereafter the same shall be in full force and effect. APPROVED AND ADOPTED this 17th day of December, 2007. ATTE T: MAN ELA GIRON, City Clerk Name: Leonis C. Malburg Title: Mayor / - 3 - 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 STATE OF CALIFORNIA ) ) ss COUNTY OF LOS ANGELES ) I, MANUELA GIRON, City Clerk of the City of Vernon, do hereby certify that the foregoing Resolution, being Resolution No. 9497, was duly adopted by the City Council of the City of Vernon at a regular meeting of the City Council duly held on Monday, December 17, 2007, and thereafter was duly signed by the Mayor or Mayor Pro-Tem of the City of Vernon. (SEAL) L."�2 L�= '- UELA GIR N City Clerk - 4 - EXHIBIT A XAetna7 Employer Application ' (for Aetna use only) 1 469704 Per California Law, wherever the term "Dependent" appears, it shall Include a Domestic Partner. Company Name: City of Vernon Street Address: 4305 S. Santa Fe Avenue CRY: Vernon State: CA Zip Code: 90058 Federal Tax ID Number: 95 - 6000808 Parent Company name (if applicable) The purpose of the application is to request: a. Issuance of new coverage b. change in existing coverage C. extension of existing coverage to additional groups of employees Medical Coverage Selection: Provided or administered by Aetna Life Insurance Company and Aetna Health of California Inc., For For For Type of Coverage Employees Dependents Retirees Contributory Q Non -Contributory Medical Stand -Alone Dental Coverage Selection: Provided or administered by Aetna Dental of California Inc. and Aetna Life Insurance Comnanv. For Employees For Dependents For Retirees Type of Coverage Contributory Q Q Q Dental Coverage Non -Contributory Q Q 0 Life, Disability, and Long Term Care: Provided or Administered by Aetna Life Insurance Comnanv For Employees For Dependents For Retirees Type of Coverage Contributory Q Q Q Basic Term Life Insurance Non -Contributory Q Q Q Dependents' Maximum subject to state law Contributory Q Q Supplemental Term Life Insurance Non -Contributory Q Q Q Dependents' Maximum subject to state law Contributory Q Not Accidental Death & Personal Loss Coverage Non -Contributory Q Q Available Contributory Q Q Not Non -Contributory Q Q Available Supplemental Accidental Death & Personal Loss Coverage GR-23-7 (6(07) CA N8007 Master Application Contributory Q Not Not Long Term Disability Non -Contributory Q Available Available Contributory Not Not Short Term Disability Non -Contributory Q Available Available Contributory Long Term Care Non -Contributory Q Q Q Contributory Q Non -Contributory Other: Retiree Over 65 General enrollment and efigibIlIty section Requested effective date: 1/1/2008 (Actual effective date will be assigned by Aetna If the application is accepted and a policy Issued.) Applicant will utilize electronic enrollment (check one): Yes No This application includes the following member employers. (Any entry in conflict with applicable law cannot be included): Additional sheets may be added if necessary. Located At Located At Located At 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). If more space is needed, please attach an additional sheet. Agent(s) of Record: Name: Signature: License #: General Agent Name: Signature: License #: Applicant Acknowledgements and Agreements 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 an authorized representative of Aetna, to make contributions for contributory coverage at a rate higher than the initial contribution rate applicable for the employee's then current coverage. With the exception of Arizona (refer to group applicant paragraph below), 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 (subject to applicable HIPAA requirements for health coverage), unless otherwise specifically agreed to by Aetna and provided in the plan documents (which consist of the Group Policy and/or Group Agreement). All statements herein shall be deemed representations and not warranties. The Applicant acknowledges that it has selected the coverage specified herein based upon written information provided by Aetna and that no broker, agent or consultant is authorized to modify the terms of the offer or to agree to changes. All material terms of coverage are set forth in the plan documents. Applicant agrees to make payroll and other records directly related to employee's coverage under the Group Policy and/or Group Agreement available to Aetna for inspection, at Aetna's expense, at Applicant's office, during regular business hours, upon reasonable advance request. This provision shall survive termination of the Group Policy and/or Group Agreement. Applicant has selected, in accordance with applicable state law, the coverage to be offered to Applicant's employees and Applicant has solely determined any/all coverage options for the Applicant's employees and the contribution amounts. The plan documents will determine the contractual provisions, including procedures, exclusions and limitations relating to the coverage and will govern in the event they conflict with any benefits comparison, summary or other description of the coverage. See below for applicable provisions. GR-23-7 (6107) CA N13007 Master Application Applicant Acknowledgements and Agreements (Continued) With the exception of Aetna Fix Home Delivery, all participating providers and vendors are independent contractors and are neither agents nor employees of Aetna. Aetna Rx Home Delivery, LLC, Is a subsidiary of Aetna Inc. The availability of any particular provider cannot be guaranteed, and provider network composition is subject to change. Notice of the change shall be provided in accordance with applicable state law. Aetna does not provide health or dental care services and, therelore, cannot guarantee any results or outcome. Some benefits are subject to limitations or maximums. In accordance with current IRS regulations and the 1906 Tax Reform Act, a life insurance position schedule may be deemed discriminatory and result in imputed income lax to certain employees and possibly an excise tax to employers. Employers should consult with legal counsel prior to electing a position schedule. Aetna disclaims any responsibility If the employer elects such a position schedule and it is later deemed discdminatory. Applicant agrees to deliver or otherwise make available to enrollees all Aetna paper or on-line member documents and other plan related materials upon request by Aetna. All data that may have a bearing on coverage or premiums will be open for Aetna to inspect while the Group Agreement and/or Group Policy is in force. The availability of a plan or program may vary by geographic service area. 'Aetna' is the brand name used for products and services provided by one or more of the Aetna group of subsidiary companies. Important Information 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. Information CALIFORNIA NOTICE: California law prohibits an HIV test from being required or used by health Insurance companies as a condition of obtaining health Insurance coverage. CALIFORNIA HMO APPLICANTS: Any dispute arising from or related to the Group Agreement will be determined by submission to binding arbitration, and not by a lawsuit or resort to court process except as California law provides for judicial review of arbitration proceedings. The agreement to arbitrate Includes, but Is not limited to, disputes Involving alleged professional liability or medical malpractice, that is, whether any medical services covered by the Group Agreement were unnecessary or were unauthorized or were improperly, negligently or Incompetently rendered. This agreement also limits certain remedies and may limit the award of punitive damages. See Sections "Binding Arbitration" and "Limitations on Remedies" of the Evidence of Coverage for further Information. The undersigned representative of the Employer understands that the Employer and any Groups eligible through the Employer, if different from the Employer, and any Members who enroll under this health plan are giving up their constitutional right to have any such dispute decided In a court of law before a jury, and Instead are accepting the use of binding arbitration. This means that the Employer, Groups, Members and other Interested parties will not be able to try their case In court. The undersigned representative of the Employer further understands and accepts that the Employer, Groups and Members are giving up certain remedies and that there may be certain limitations to the recovery of punitive Signature Section I hereby apply for the coverage(s) indicated above. I certify that all information provided in this application is accurate and complete. I understand that this application will form a part of the Group Agreement and/or Group Policy issued by Aetna and by my signature below I agree to be bound by the terms and conditions of that Group Agreement and/or Group Policy. I understand that Aetna may choose not to accept this application at its sole discretion, subject to any state requirements. Signed at (location): Grin ` `' } ( �/ t OeG (, „ City Of Vernon City�tai9�, Applicant (Company Name) Authorzd Ap iiI t3i ture (Official Title 1 , witnes Date L � ILA Your premium purchases insurance beverage 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. Please keep a copy of this application for your records. If the application is accepted by Aetna it becomes part of the issued Group Agreement and/or Group Policy. GR-23-7 (6/07) CA NB007 Master Application XAetna CALIFORNIA Notice of Election Or Rejection Of Optional Benefits Instructions 1. Benefit - Comprehensive infertility services including Gamete Intra-fallopian Transfer ("GIFT") Optional coverage does not apply to ASCs. 2. Benefit - Substance Abuse Treatment in a Licensed Treatment Facility Optional coverage does not apply to ASCs. • Traditional ALIC-based products (e.g. MC, EC, PPO etc.) meet the mandate to offer with a 45 day licensed treatment facility benefit. • HMO based products_ meet the mandate to offer with the Substance Abuse Rehabilitation Option NB988 - CA Election/Rejection Form rev: 07-29-03 Meftife Metropolitan Life Insurance Company 200 Park Avenue, New York, New York 10166 APPLICATION FOR GROUP INSURANCE The applicant named below is applying for a Group Policy to provide insurance for the persons specified below. APPLICANT DATA 1. Full legal name of Applicant: City of Vernon (the "Policyholder") 2. Address: 4305 Santa Fe Ave. City Vernon State CA Zip 90058 POLICY EFFECTIVE DATE The Group Policy's effective date will be January 1, 2008 , subject to MetLife's acceptance of this application and the Applicant's payment of the Premium due on or before such date. POLICY SITU$ The Group Policy will be issued for delivery in and governed by the laws of California COVERAGE DATA Employees / Members Employees / Members Only and Dependents Basic Life (or Core) ❑ ❑ Basic Life with AD&D (or Core) ❑ Enhanced Optional Life ❑ ❑ Enhanced Optional Life with AD&D ❑ ❑ Buy Up Life ❑ ❑ Buy Up Life with AD&D ❑ ❑ Dental ❑ 1 Long Term Disability ❑ Short Term Disability ❑ PREMIUM DATA Premiums will be paid: ❑ monthly ❑ quarterly ❑ annually ❑ other: Attached is an advance payment of. $ AGREEMENT The Applicant signing below agrees to accept the terms and provisions of the Group Policy, including its Exhibits, amendments and endorsements, if any. . Fraud Warning. Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or a 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 critne and subjects .such person t criminal and civil penalties. f7C� Legal resentative) (Print Name and Title of Legal kpresentative) Date: (State) �t / r le - (Print Narfie of Witness) (Signature of Licensed MetLife Agent or Resident (Agent's State License No.) (Print Name of Agent) Agent as required by law) APP-GP99 NW/F Group Employer Medicare Advantage Plans (MA) and Medicare Prescription Drug Plan (PDP) Application Applicant Policy or Group Number (for Aetna use only) Company Name: City Of Vernon Street Address: 4305 S. Santa Fe Avenue City: Vernon State: CA Zip Code: 90058 Federal Tax ID Number: Parent Company name (if applicable) The purpose of the application is to request: a. X issuance of new coverage b. change in existing coverage C. extension of existing coverage to additional groups of retirees Medicare Coverage For Retirees Type of Coverage Contributory Medicare Advantage HMO, provided and administered by Aetna Health Inc. in AZ, DC, FL, GA, MD, NJ, Non -Contributory Q NY, OH, PA, VA and TX, Aetna Health of California Inc. in CA, and Aetna Contributory Q Medicare Advantage PPO, Non -Contributory provided and administered by Aetna Life Insurance Company Contributory Medicare Private Fee -for -Service (PFFS), Non -Contributory provided and administered by Aetna Life Insurance Company Contributory Q Medicare Prescription Drug Plan (PDP), Non -Contributory provided and administered by Aetna Life Insurance Company General enrollment and eligibility section Requested effective date: 1 /1 /2008 (Actual effective date will be assigned by Aetna if the application is accepted and a policy issued.) Renewal date: 1 /1 /2009 (For Medicare Advantage plans with Medicare prespeription drug coverage ("MA-PD plan") and standalone PDPs, the renewal date must by January 1) Applicant will utilize electronic enrollment Yes ® No (check one): Late Enrollment Penalty Attestation (Please review and complete if applying to obtain coverage under a PDP or MA PDP plan) Pursuant to Section 1860D-13(b) of the Social Security Act and 42 C.F.R. Sections 423.46 and 423.56(g), Medicare beneficiaries may incur a late enrollment penalty (LEP) if there is a continuous period of 63 days or more at any time after the end of the individual's Medicare Part D initial enrollment period during which the individual was eligible to enroll, but was not enrolled in a Medicare Part D plan and was not covered under any creditable prescription drug coverage. "Creditable prescription drug coverage" is prescription drug coverage that is expected to pay at least as much as Medicare's standard prescription drug coverage. To ease the administrative burden associated with implementation of these new LEP-related procedures, the Centers for Medicare and Medicaid Services (CMS) permits Medicare prescription drug plan sponsors and Medicare Advantage (MA) Organizations to accept attestations from employers wherein the employer attests to the creditable coverage history of individuals submitted for enrollment in the employer group's Medicare prescription drug plan for purposes of reporting covered months. Yes, Applicant will attest to the creditable prescription drug coverage history of all individuals submitted by Applicant for enrollment in Aetna's Medicare Advantage plans with prescription drug coverage ("MA -PO plans") or Aetna's Medicare prescription drug plans ("PDPs") for purposes of reporting covered months. By checking this box and signing this Application, Applicant attests that all individuals submitted for enrollment in Aetna's MA-PD plans or PDPs were either previously enrolled in another Medicare prescription drug plan or had other creditable prescription drug coverage prior to applying to enroll in an Aetna MA-PD plan or PDP. Applicant understands that by signing this Application, Applicant is attesting that it has read and understands the contents of this attestation and that this attestation is truthful, accurate and complete. Q No, Applicant will not attest to the creditable prescription drug coverage history of all individuals submitted for enrollment in Aetna's MA-PD plans or PDPs for purposes of reporting covered months. Applicant understands that without an attestation from Applicant, all individuals submitted by Applicant for enrollment in MA-PD plans or PDPs will be submitted by Aetna through CMS systems to determine if gaps of 63 days or more exist in creditable prescription drug coverage since the close of the individual's initial Medicare Part D enrollment period. Individuals who are identified to have such gaps of creditable prescription drug coverage will receive letters requesting that they attest to any creditable prescription drug coverage during those gaps, and these individuals may contact Applicant for assistance in determining creditable coverage history. Applicant Acknowledgements and Agreements The Applicant agrees that at no time shall any individual submitted by Applicant for enrollment in an Aetna Medicare plan ("Enrollee") be permitted or required to contribute for non-contributory coverage; or, unless the change is approved in writing by an authorized representative of Aetna, to make contributions for contributory coverage at a rate higher than the initial contribution rate applicable for the Enrollee's then current coverage. It is agreed that no coverage shall become effective as to any person who is not then a (1) bona fide, full-time employee regularly performing the duties of his or her occupation (subject to applicable HIPAA requirements for health coverage)„ (2) a bona fide retiree of Applicant, or (3) an eligible dependent of such retiree or employee, unless otherwise specifically agreed to by Aetna and provided in the plan documents (which consist of the Group Agreement and Evidence of Coverage). All statements herein shall be deemed representations and not warranties. The Applicant acknowledges that it has selected the coverage specified herein based upon written information provided by Aetna and that no broker, agent or consultant is authorized to modify the terms of the offer or to agree to changes. All material terms of coverage are set forth in the plan documents. Applicant agrees to make payroll and other records directly related to an Enrollee's coverage under the Group Agreement available to Aetna for inspection, at Aetna's expense, at Applicant's office, during regular business hours, upon reasonable advance request. This provision shall survive termination of the Group Agreement. Applicant has selected, in accordance with applicable law, the coverage to be offered to Applicant's employees and/or retirees and their eligible dependents and Applicant has solely determined any/all coverage options for the Applicant's employees and/or retirees and their eligible dependents and the contribution amounts. The plan documents will determine the contractual provisions, including procedures, exclusions and limitations relating to the coverage and will govern in the event they conflict with any benefits comparison, summary or other description of the coverage. With the exception of Aetna Pox Home Delivery, all participating providers and vendors are independent contractors and are neither agents nor employees of Aetna. Aetna Rx Home Delivery, LLC, is a subsidiary of Aetna Inc. The availability of any particular provider cannot be guaranteed. With respect to those Aetna Medicare plans that are network -based, provider network composition is subject to change. Notice of a change in provider network composition shall be provided to Enrollees in accordance with applicable federal law. Aetna does not provide health or dental care services and, therefore, cannot guarantee any results or outcome. Some benefits are subject to limitations or maximums. Applicant agrees to deliver or otherwise make available to Enrollees all Aetna paper or on-line member documents and other plan related materials upon request by Aetna. All data that may have a bearing on coverage or premiums will be open for Aetna to inspect while the Group Agreement is in force, and as required under applicable laws, rules and regulations and the Group Agreement, The availability of a plan or program may vary by geographic service area. "Aetna" is the brand name used for products and services provided by one or more of the Aetna group of subsidiary companies. Important Information Any person who knowingly and with intent to injure, defraud or deceive 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. Any dispute arising from or related to the Group Agreement will be determined by submission to binding arbitration, and not by a lawsuit or resort to court process except as applicable law, as defined in the "Applicable Law" section of the Group Agreement, provides for judicial review of arbitration proceedings. The agreement to arbitrate includes, but is not limited to, disputes involving alleged professional liability or medical malpractice, that is, whether any items and/or medical services covered by the Group Agreement were unnecessary or were unauthorized or were improperly, negligently or incompetently rendered. This agreement also limits certain remedies and precludes the award of punitive damages. See sections "Binding Arbitration" and "Limitations on Remedies" of the Evidence of Coverage for further information. The undersigned representative of the Applicant understands that the Applicant and any Groups eligible through the Applicant, different from the Applicant, and any individuals who are submitted by Applicant for enrollment in an Aetna Medicare plan ("Members") are giving up their constitutional right to have any such dispute decided in a court of law before a jury, and instead are accepting the use of binding arbitration. This means that the Applicant, Groups, Members and other interested parties will not be able to try their case in court. The undersigned representative of the Applicant further understands and accepts that the Applicant, Groups and Members are giving up certain remedies and that there may be certain limitations to the recovery of punitive damages. Signature Section I hereby apply for the coverage(s) indicated above. I certify that all information provided in this application is accurate and complete. I understand that this application will form a part of the Group Agreement issued by Aetna and by my signature below I agree to be bound by the terms'and conditions of that Group Agreement. I understand that Aetna may choose not to accept this application at its sole discretion, subject to any federal and/or state requirements. Signed at (locatio (?, -7�Olzllw Appiicant (Company Name) /er s /—/ {-,�'J G-eg- - Official Title . Date Your premium purchases 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. Please keep a copy of this application for your records. If the application is accepted by Aetna it becomes part of the issued Group Agreement. New Group Submission Checklist To allow sufficient processing time, all submission _ q materials need to be submitted prior to the requested effective date. if the insurance is currently in -force, please do not cancel coverage until receipt of risk acceptance letter from MetLife. Making benefits administration easier requires a solid foundation. To help ensure that your case is set up correctly, you must submit the information requested below. Required attachments: ❑ APPLICATION FOR GROUP INSURANCE (Note state specific forms: FL, KS/MA, NJ, NY, OK, OR & VA all other states use Nationwide form.) If PA sold with PDP Dental attach an additional PA group application form. ❑ DEPOSIT CHECK equal to approximately I" month's premium. (For 15"' of month effective date, remit I %2 month's premium.) ❑ RISK ASSESSMENT SUMMARY (For all coverages except Dental) ❑ COPY OF SOLD PROPOSAL (Confirmed by Sales Rep) ❑ PRIOR CARRIER'S BOOKLET & BILL (For takeover groups) ❑ ENROLLMENT CARDS for Contributory Coverages (Waiver Section must be completed for all employees waiving coverage.) For Non -Contributory Coverages: Census list can replace cards, listing applicable employee information including: Full Name, Address, Marital Status, Social Security Number, Birth date, Gender, Hire Date, Job Title, Salary and Mode, Worksite Zip Code and Class. ❑ eCensus: Enrollment cards should be maintained by employer. Census should be sent email to sales office. If Applicable: ❑ STATEMENT OF HEALTH FORMS for employees/dependents applying for life amounts greater than non-med max or employees not on prior plan. (State -specific forms for employees whose worksite zip code are in CA, CT, FL, IN, ME, MD, MN, NY, VT, VA or WI.) PROOF OF COBRA ELECTIONS (Copy of dated COBRA election form) Groups with fewer than 20 lives are not eligible for COBRA. ❑ PROOF OF ACTIVE FULL-TIME EMPLOYMENT for eligible employees age 70 and over (W-2/ Tax Wage Report or Employer Confirmation on Company letterhead or email from company rep) Only applies to 2-99 lives, 100+ lives no proof req. ❑ CORE BUY -UP OR ENHANCED OPTIONAL LIFE: Signed Portability Forms (2 original copies); and if Optional/Buy-Up AD&D is purchased: Signed TravelAssistance Agreement and 24-hr contact name/phone #: ❑ EAP: If Employee Assistance Program is sold with LTD: Signed MetLife EAP Agreement ❑ UNIONS (If union employees are to be covered, please provide all applicable pages of the Collective Bargaining Agreement(s).) Has the group entered into an agreement with a PEO (Professional Employer Organization)? ❑ Yes n No If Yes, are the employees employed by the PEO? ❑ Yes ❑ No GROUP INFORMATION Group Name: (Full Legal Name — Please include exact abbreviations, punctuation and/or capitalization.) City of Vernon Effective Date: January 1, 2008 Renewal Date: January 1, 2010 Industry: G.ROUP'S HOME OFFICE ADDRESS INFORMATION Street Address: 4305 Santa Fe Ave. City: Vernon State: CA ZIP: 90058 Situs State: California Employer Tax ID: 95-6000808 GROUP'S BILLING / MAILING ADDRESS INFORMATION (if different from home office address provided above) Name: Street Address: City: State: ZIP: EXECUTIVE CONTACT INFORMATION (Authorized to make plan changes) Name: Willard Yamaguchi E-Mail Address: wyamaguchi@ci.vernon.ca.us Phone Number:' 323 583-8811 x175 FAX: 323 826-1439 DIVISION CONTACT/BENEFIT ADMINISTRATOR INFORMATION Name: Karina Rueda E-Mail Address: krueda@ci.vernon.ca.us Phone Number (include extension): (323) 583-8811 x325 FAX: (323) 826-1439 # of Employees employed by group: 300 # of Employees eligible for coverage: 300 SIC Code: If more space is needed, please attach a separate page. Meftife' Small Business Center Version 09/13/07 Page 1 of 5 PRIOR OR CURRENT COVERAGE WITH METLIFE? 0 Yes No If yes, MetLife Customer Number: In -Force MetLife Coverages: ❑ Group Life ❑ STD ❑ LTD ❑ Dental ❑ Voluntary Life PRIOR CARRIER COVERAGE? ®Yes ❑ No Name of Prior Carrier: United Concordia via Mutual of Omaha Coverages: ❑ Qroup Life ❑ STD ❑ LTD N Dental ❑ Voluntary Life Please com lete the following subsidiary information if there are em Jo ees working for a subsidia who are eli ible for coverage. SUBSIDIARIES (If more than one, please provide the following information for all subsidiaries.) Subsidiary Name (1): TIN: Separate Bill?* ❑ Yes ❑ No Number of Employees: Street Address: City: State: ZIP: Contact Name: Phone: Fax: Subsidiary Name (2): TIN: Separate Bill?* ❑ Yes ❑ No Number of Employees: Street Address: City: State: ZIP: Contact Name: Phone: Fax: * Not applicable for groups with 2 — 9 lives. If more svace is needed. please attach a separate oaae_ CERTIFICATE INFORMATION Issue: ® Same Certificates for entire group ❑ Division -specific Certificates ❑ Class -specific Certificates Mail Certificates to: ® Employer ❑ Broker ❑ TPA ❑ GA Other: AV VJ I IOINAL ENKULLIVILIN r INFORMATION: Student Age (Dependent Life and Dental): ❑ 19/23 ❑ 19/25* State -Mandated Other 19/24 *Only option available for groups with 2-9 lives. DEPENDENT ROSTERING Initial Enrollment will include dependent information (name gender, DOB and relationship,). ❑ Yes ❑ No (Important: If dependent information is not included with initial enrollment, it may cause delays when claims are filed.) DOMESTIC PARTNERSHIP ® Yes ❑ No Opposite sex only Employee Eligibility (restricted for 2-9 life groups): ❑ Standard (Full-time, active employees working at least 30 hours per week.) ® Other: Full time, active employees scheduled to work an average of at least 40 hours per week Present Employees (hired on or before the effective date): ❑ None* ❑ 30 Days ❑ 60 Days ❑ 90 Days ❑ One Month ❑ Three Months ® Other: First of the month following date of hire unless employee is hired on first of month. If hired on first of month then coverage will begin on first * Employees in the waiting period on the effective date of the policy will have the remainder of the waiting period waived. Future Employees: ❑ None ❑ 30 Days ❑ 60 Days ❑ 90 Days ❑One Month ❑ Three Months ® Other: First of the month following date of hire unless employee is hired on first of month. If hired on first of month then coverage will begin on first. Class Specific Waiting Period? Class 1: Class 2: Class 3: Individual Effective Date (following ❑ Date Eligible ❑ First of the Month waiting period): Coverage will end on the I First of the Month following the waiting period. Coverage Employment Termination Date. I will end on the last day of the month following termination. CLASS DESCRIPTIONS (restricted for 2-9 life groups) ❑ All Active full-time employees ❑ Other: Class 1: Class 2: ❑ Other: Class 3: Class 4: Lue and Mental Uontributions Ij more space is needed, please attach a separate page. Employer Contribution Percentage: (Minimum of 25% is required — except for Voluntary lines of coverage.) If the em lover pays 100% of the premium, eligible em loyees must articipate. Employer contribution % on Behalf Of: Employees Dependents ❑ Basic Life/AD&D % % Core Buy -Up Life/AD&D Core: 100%/Buy-Up: 0% 0% Enhanced Optional Life/AD&D 0% 0% ❑ Dental PPO 100% 100% Version 09/13/07 Page 2 of 5 ❑ Dental DHMO % % ❑ Voluntary Dental % % Disability Contributions and Reporting Information Employer Contribution % on Behalf of Employees: (Minimum of 25% is required — except for Voluntary lines of coverage.) ❑ Long Term Disability (LTD) % ❑ Short Term Disability (STD) % Benefit Payments derived from Employer Contributions are 100% taxable for the Employee. If the Em toyer pays 100% of the premium, all eligible Employees must participate. Employee Contribution %: ❑ Long Term Disability (LTD) % ❑ Pre -Tax ❑ Post -Tax ❑ Short Term Disability (STD) % ❑ Pre -Tax ❑ Post -Tax El Voluntary STD* % ❑ Pre -Tax ❑ Post -Tax *Voluntary STD 100% Employee paid (Standard). The Employer may pay 0% to 25% of the premium and still qualify for coverage to the provided group. Employee Pre -Tax contributions are 100% taxable for the Employee. Employee Post -Tax contributions are 0% taxable for the Employee. Note: The total Employer and Em We Contribution % for STD and/or LTD must each equal 100% Disability Tax Reporting for W2s: ❑ MetLife will issue W2s for: ❑ LTD ❑ STD ❑ Customer will issues W2s for: ❑ LTD ❑ STD Mail Employee original W2s to: ❑ Employee (Standard) ❑ Employer The Employer will receive an Employer W2 report annually if MetLife issues the W2s. Note: The benefits must be taxable or MetLife's system will not produce a W2. Detailed Benefit Reports providing Employee payment and tax withholding information: Report Mailing Frequency: ❑ Quarterly (Standard) ❑ Monthly Report Transaction Activity Aggregation: ❑ Cumulative (Standard) ❑ Non -Cumulative Note: The Employer will receive both W2 if MetLife issues and Detailed Benefit Reports monthl / uarterl . STD Checks Mailed to: Claimants (Standard) Note: If the Employer has more than one plan and the information for each plan is not identical, please complete and attach a Disability Contribution and Reporting Information sheet for each plan. Basic Earnings Definition (if nothing is checked, we will assume basic earnings only): Basic Life/AD&D ❑ Include Commissions Only Include Bonuses Only El Commissions & Bonuses STD ❑ Include Commissions Only ❑ Include Bonuses Only ❑ Commissions & Bonuses LTD ❑ Include Commissions Only ❑ Include Bonuses Only ❑ Commissions & Bonuses Average Commissions ❑ 12 Months [] 24 Months ❑ 36 Months * Commissions and Bonuses are available for Sales Employees Only BILLING DETAIL Billing Administration: ❑ List Bill* ❑ TPA Billed** ❑ Self Administered (SAP)*** ❑ Group Tape Feed **** *Under 100 lives: List Bill only. All Voluntary products must be list billed, regardless of size. * *C&A Agreement must be completed ***All 200+ lives groups must be SAP billed, except for voluntary products. ****250+ lives or min.75k annual premium. Restrictions: y products. Include Approval a -mail. Provide Group Tape Vendor Name: No MetLink and No Voluntar EMPLOYEES NOT ACTIVELY AT WORK Please list any current employees not actively working (excluding employees on vacation) as of the effective date. These employees must be disclosed and are not eligible for coverage until they return to work. Name: Reason: Name: Reason: Name: Reason: Comments: Version 09/13/07 Page 3 of 5 SECTION 125 Do you have a Dental Section 125 Plan? ❑ Yes ® No ERISA Include ERISA in your certificate booklets? ❑ Yes 0 No If you checked "Yes" above, answer the following: Plan Year Ends: ❑ Calendar Year ❑ Policy Year ❑ Fiscal Year -provide fiscal year date: Administrator: ❑ Employer ❑ Union Maintaining Plan ❑ Other - If other, please provide: Name: Address: Coverage's: I ❑ Basic Life/AD&D ERISA Plan #: ❑ STD ERISA Plan #: ❑ LTD ERISA Plan #: I Ej Dental ERISA Plan #: PRODUCER INFORMATION Currently appointed with Metropolitan Life Insurance Co.? 0 Yes No* Broker Code (if available): Writing Producer's Name: Brenda Lee Writing Producer's Social Security #: Writing Producer's State Insurance License Number: OA24484 Commission Paid to: ElIndividual M Corporation Individual Commission %: Split Commission %: (Complete 2"d Producer Info. below Corporation Name: Gallagher Benefit Services, Inc. Corporate Federal Tax ID: 364291971 Corporate Address: 505 N. Brand Blvd., Suite 600, Glendale, CA 91203 Producer Address: If commissions are paid to an entity or individual other than the producer, provide payee name, address, phonefar, and e-mail address. Broker's Resident Address: Payee Address (if different from above): City: I State: ZIP: Contact at Producer's Office — Name: Phone: I FAX: E-Mail Address: Strategic Alliance Information N/A ❑ GA El TPA Broker Name: Broker Code: Social Security #: Strategic Alliance Agency Name: Tax ID#: Contact Name: Contact Phone: Contact FAX: Contact E-Mail Address: * If licensingpaperwork is received, please fax the paperwork to the Licensing Unit at 1-800-556-9430. 2nd PRODUCER INFORMATION: (For split commissions) Currently appointed with Metropolitan Life Insurance Co.? Yes ❑ No* I Broker Code (if available): Writing Producer's Name: Writing Producer's Social Security #: Writing Producer's State Insurance License Number: Commission Paid to: El Individual ❑ Corporation Split Commission %: Corporation Name: Corporate Federal Tax ID: Corporate Address: Producer Address`. I commissions are aid to an entity or individual other than the producer, provide payee name, address, phonefax, and e-mail address. Broker's Resident Address: Payee Address (if different from above): City: State: ZIP: Contact at Producer's Office — Name: Phone: FAX: E-Mail Address: Strategic Alliance Information N/A ❑ GA EITPA Broker Name: Broker Code: Social Security #: Strategic Alliance Agency Name: Tax ID#: Contact Name: Contact Phone: Contact FAX: Contact E-Mail Address: * If licensing paperwork is received, please fax the paperwork to the Licensing Unit at 1-800-556-9430 METLIFE CAREER AGENT INFORMATION (if applicable) Agent Name: I Employee #: Territory #: Region: District #: Agency#: Index #: Split Commission % Version 09/13/07 Page 4 of 5 METLINK USER AUTHORIZATION INFORMATION (if applicable — MetLink not available for groups with less than 10 lives or for Dual Option DHMO cases. User (1): First Name Karina Last Name: Rueda Business Email Address: krueda@ci.vernon.ca.us Company Name: City of Vernon Business Phone: (323) 583-8811 x325 Business Address: 4305 Santa Fe. Ave. City: Vernon State: CA ZIP: 90058 Brokers Only - Do you currently have an existing MetLink user ID? Yes No User ID: User (2): First Name Last Name: Business Email Address: Company Name: Business Phone: Business Address: City: State: ZIP: Brokers Only - Do you currently have an existing MetLink user ID? El Yes D No User ID: The following MetLink features will be assigned to all users: • Enrollment / Eligibility - Update and Inquiry • Resources (User Guide & Legislative releases) • On Line List Billing (access will be given ONLY if you are a List Bill customer) • STD / LTD Disability Claim Status Inquiry and Online filing (Access will be given ONLY if you have disability insurance) • Dental Claims Inquiry (Access will be given ONLY if you have dental insurance and are HIPAA certified) Please note: MetLife dental customers must comply with all HIPAA requirements as well as become certified with MetLife in order to obtain access to the Dental Claim Inquiry feature of MetLink. COMMENTS M Benefits: Yes ❑ No ❑ I Request for MetDESK Onsite Workshop (Group Life customers only): Yes ❑ No FARM COMPLETED BY: Employer (Benefits Administrator) ❑ Broker ❑ TPA ❑ GA ❑ Sales Rep BENEFIT ADMINISTRATOR CALL Please Note: MetLife's standard policy is for our Issue Underwriter to make a "Welcome Call" to the benefits administrator. This will ensure that the information we have is correct, and will answer any questions the group has before the policy is issued. BA should maintain enrollment cards if e-Census provided. HIPAA Information: (This section pertains to MetLife Dental customers only) I am an authorized representative of the MetLife customer named on page 1. I have read and understand the SBC HIPAA Information For New MetLife Group Dental Insurance Customers. By my signature at end of this form, I confirm that the customer: (select ONE of the three options listed below) ❑ Does not wish to have access to employee's Protected Health Information (PHI). ❑ Has submitted a copy of a signed HIPAA Plan Sponsor Certification Form indicating that the customer has already amended their plan document to include HIPAA language required to permit disclosure of PHI to the plan sponsor. (To be created by customer legal advisor) 14, Has reviewed and adopted the Sample SPD HIPAA Privacy Language for use in its summary plan description. The customer has submitted a completed and signed copy of the HIPAA Request Form. ❑ By checking this box and signing below, I certify that the Gramm -Leach -Bliley Privacy Notice has been distributed to all affected employees. If ental coverage is selected: DgjBy checking this box and signing below, I certify that I received a copy of the SBC HIPAA Information for New MetLife roup Dental Insurance Customers. Sig tur of Ben Administrator (or any employee �t brked to make plan changes — i.e. President) Date Version 09/13/07 Page 5 of 5 XAetnd Employer Application Applicant (for Aetna use only) Per California Law, wherever the term "Dependent" appears, it shall include a Domestic Partner. Company Name: City of Vemon Street Address: 4305 S. Santa Fe Avenue City: Vernon State: CA Zip Code: 90058 Federal Tax ID Number: 95 - 6000808 Parent Company name Qf applicable) The purpose of the aplAcation is to request: a. issuance of new coverage b. change in existing coverage C. extension of eAsting coverage to additional groups of employees Medical Coverage Selection: Provided or administered by Aetna Life Insurance Company and Aetna Health of California Inc., For For For Type of Coverage ees Dependents Retirees Contributory Medical Non -Contributory Q Q [- Stand -Alone Dental Coverage Selection: Provided or administered by Aetna Dental of California Inc. and Aetna Life Insurance Comnanv_ For Frrt bo eas For Dependents For Retirees Type of Coverage Contributory Q Q Q Dental Coverage Non -Contributory Q Q Q Life, Disability, and Long Tenn Care: Provided or Administered by Aetna Life Insurance Company For For For Type of Coverage Employees Dependents Retkees Contributory Q Q Q Basic Tenn Life Insurance Non -Contributory Q Q Q Dependents' Maximum subject to state law Contributory Q Q Supplemental Tenn L fe Insurance Non -Contributory Q 0 Q Dependents' Maximum subject to state law Contributory Q Q Not Accidental Death & Personal Loss Coverage Non -Contributory Q Q Available Contributory Q Q Not Non -Contributory Q Q Available Supplemental Accidental Death &Personal Loss Coverage GR-23-7 (6I07) CA N8007 Master Application With the exception of Aetna Rx Home Delivery, all participating providers and vendors are independent contractors and are neither agents nor employees of Aetna. Aetna Rx Home Delivery, LLC, is a subsidiary of Aetna Inc. The availability of any particular provider cannot be guaranteed, and provider network composition Is subject to change. Notice of the change shall be provided In accordance with applicable state law. Aetna does not provide health or dental care services and, therefore, cannot guarantee any results or outcome. Some benefits are subject to limitations or maximums. In accordance with current IRS regulations and the 19M Tax Reform Act, a life insurance position schedule may be deemed discriminatory and result in imputed income lax to certain employees and possibly an excise tax to employers. Employers should consult with legal counsel prior to electing a position schedule. Aetna disclaims any responsibility If the employer elects such a position schedule and it is later deemed discriminatory, Applicant agrees to deliver or otherwise make available to enrollees all Aetna paper or on-line member documents and other plan related materials upon request by Aetna. All data that may have a bearing on coverage or premiums will be open for Aetna to inspect while the Group Agreement and/or Group Policy is in force. The availability of a plan or program may vary by geographic service area. "Aetna" is the brand name used for products and services provided by one or more of the Aetna group of subsidiary companies. Important Information 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 fad material thereto, commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties. CALIFORNIA NOTICE: California law prohibits an HIV bast from being required or used by health Insurance companies as a condition of obtaining health Insurance coverage. CALIFORNIA HMO APPLICANTS: Any dispute arising from or related to the Group Agreement will be detertnNned by submission to binding arbitration, and not by a lawsuit or resort to court process except as California law provides for judicial review of arbitration proceedings. The agreement to arbitrate Includes, but Is not limited to, disputes Involving alleged professional liability or medical malpractice, that Is, whether any medical services covered by the Group Agreement were unnecessary or were unauthorized or were Improperly, negligentty or incompetently rendered. This agreement also Ilmits certain remedies and may limit the award of punitive damages. See Sections "Binding Arbitration" and "Limitations on Remedies" of the Evidence of Coverage for further Information. The undersigned representative of the Employer understands that the Employer and any Groups eligible through the Employer, if different from the Employer, and any Members who enroll under this health plan are giving up their constitutional right to have any such dispute decided In a court of law before a jury, and Instead are accepting the use of binding arbitration. This means that the Employer, Groups, Members and other Interested parties will not be able to try their case In court The undersigned representative of the Employer further undenstands and accepts that the Employer, Groups and Members are giving up certain remedies and that there may be certain limitations to the recovery of punitive damages. Signature Section I hereby apply for the ooverage(s) indicated above. I certify that all information provided in this application is accurate and complete. I understand that this application will form a part of the Group Agreement andfor Group Policy issued by Aetna and by my signature below I agree to be bound by the terms and conditions of that Group Agreement and/or Group Policy. I understand that Aetna may choose not to accept this application at its sole discretion, subject to any state requirements. Signed at (location): Vemon, Califomia City Of Vernon *77/1 Applicant (Company Name) By f Risk Manager Official Tolle 07 Dale Your premium purchases insurance co eragefromAetna, 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.setna.com. We appreciate your business and the opportunity to serve you. - Please keep a copy of this application for your records. If the application is accepted by Aetna it becomes part of the issued Group Agreement andfor Group Policy. GR-23-7 (e/07) CA NB007 Master Application 4305 Santa Fe Avenue, Vernon, California 90058 Telephone (323) 583-8811 November 29, 2007 Aetna 515 S Flower St. Suite 505 Los Angeles, CA 90071 Re: Domestic Partners Agreement Group Number: 469704 To whom it may concern: This letter will confirm that on the effective date of domestic partner coverage with one or more of the Aetna companies, all of our carriers, including any indemnity and self - insured plans, if applicable, have agreed to implement our domestic partner policy for our eligible employees and their eligible children as outlined in the attached documentation. We agree that should any future carriers commence providing coverage to our employees, including any coverage provided through a self -funded arrangement that they will agree to the domestic partner policy we have in place and is in accordance with the criteria attached. Should the policies outlined in our attachments change, we agree to forward these changes with corresponding documentation to Aetna for further review. V ry truly yours, WILLARD 4 UCHI Risk Manager E ,cfusive(y Inddustriaf HIPAA REQUEST FORM If you wish to include in your booklet certificate the HIPAA privacy language shown on the specimen "Sample Dental Booklet CertificatelSPD Language" provided to you by MetLife, please answer the following question(s), sign, and return this form to your MetLife Sales Office along with the New Group Submission Checklist. Please provide the following information: a. Are there employees of the Plan Sponsor that may access PHI (Protected Health Information) provided by the Plan? If there are, please provide their title(s) or other identifiers below. Tease do not provide their names, only title or other identifier. A9M,N5 i 9J -TiD2- b. Should the term "Privacy Officer" be included in Section Ill. (C) "Sharing of PHI with the Plan Sponsor" of the Dental Plan Document? Yes ❑ No C. Should Section IV. "Participant's Rights" be included in the Dental Plan Document? (this is an optional section). Yes ❑ No d. Should Section V. "Privacy Complaints/issues" be included in the Dental Plan Document? (this is an optional section). ,VrYes ❑ No As a duly authorized representative of the Customer named below and its group dental plan, and consistent with such Customer's decision to amend its plan document to incorporate HIPAA privacy provisions, I hereby request that MetLife include in Customer's booklet certificate HIPAA privacy language reflecting Customer's choices on this form. Customer Name L �� Customer Number 42 Authorized Signature Date 7 Formatted XAetna7 CALIFORNIA Notice of Election Or Rejection Of Optional Benefits Instructions 1. Benefit - Comprehensive infertility services including Gamete Intra-fallopian Transfer ("GIFT") Optional coverage does not apply to ASCs. 2. Benefit - Substance Abuse Treatment in a Licensed Treatment Facility_ Optional coverage does not apply to ASCs. • Traditional ALIC-based products (e.g. MC, EC, PPO etc.) meet the mandate to offer with a 45 day licensed treatment facility benefit. • HMO based products meet the mandate to offer with the Substance Abuse Rehabilitation Option NB988 - CA Election/Rejection Form rev: 07-29-03 XAetna7 CALIFORNIA Notice of Election Or Rejection Of Optional Benefits California law requires Aetna Health of California Inc. and Aetna Life Insurance Co. to offer the following coverage to employers having employees who are located in California. If elected, coverage will be provided to all employees covered under a California contract except as otherwise noted. 1. Comprehensive Infertility/GIFT Benefit In accordance with the provisions of California Health and Safety Code § 1374.55 and California Insurance Code Sections § 10119.6 and § 11512.28, this law requires insurers to OFFER to provide coverage for infertility treatment including gamete intra-fallopian transfer (GIFT), but not including in -vitro fertilization, under terms and conditions agreed upon between the group policyholder and the insurer. "Treatment of infertility" means procedures consistent with established medical practices in the treatment of infertility by licensed physicians or surgeons including, but not limited to, diagnosis, diagnostic tests, medication, surgery and gamete intra-fallopian transfer (GIFT) and other comprehensive infertility services. For under 500 eligible lives: The Comprehensive infertility/GIFT Benefit Rider covers 6 cycles of ovulation induction, 6 cycles of artificial insemination and 1 cycle of gamete intra-fallopian transfer in the lifetime of the member. • The Comprehensive infertility/GIFT Rider will not cover: 1. in -vitro fertilization (IVF); 2. zygote intra-fallopian transfer (ZIFT); 3. cryopreserved embryo transfers; or intracytoplasmic sperm injection (ICSI) or ovum microsurgery For over 500 eligible lives: The ART Benefit Rider meets the mandated offer requirements. Applicant accepts the optional Comprehensive infertility/GIFT benefit. pplicant rejects the optional Comprehensive infertility/GIFT benefit. 2. Substance Abuse Treatment in a Licensed Treatment Facility Benefit In accordance with the provisions of California Health and Safety Code § 1367.2 and California Insurance Code § 10123.6, insurers must offer coverage for treatment of alcoholism. If the policyholder chooses to cover treatment of alcoholism or chemical dependency, such treatment may take place in facilities licensed to provide such treatment other than inpatient hospital settings. • For HMO -based health plans (regulated by H&S § 1367.2), Aetna offers optional Substance Abuse Rehabilitation treatment that includes 30 inpatient days in a hospital or licensed non -hospital treatment facility. • For Traditional ALIC-based policies (regulated under Code § 10123.6), Aetna offers an optional Substance Abuse benefit of 45 days in a non -hospital licensed treatment facility. r__]Ap ant accepts the optional Substance Abuse Treatment Facility benefit. pplicant rejects the optional Substance Abuse Treatment Facility benefit. In rejecting coverage for the Applicant (Policyholder), I understand that it will not be provided at a future date unless the City Of Vernon (Group Policyholder Name) u - A - f (- 7 Title Date 469704 (Policy Control No.) NB988 - CA Election/Rejection Form rev: 07-29-03 CITY CLERK'S OFFICE INTEROFFICE MEMORANDUM DATE: January 2, 2008 TO: Willard Yamaguchi, Chief Deputy City Attorney/Risk Manager FROM: Nelly Giron, City Clerk RE: Resolution No. 9497 - A Resolution of the City Council of the City of Vernon Approving and Ratifying the actions Taken Regarding the Purchase of health, Dental and Life Benefits and Authorizing the City to Do All Actions Deemed Necessary or Advisable Concerning the Health, Dental and Life Benefits Transmitted herewith is a copy of Resolution No. 9497 referenced above, which was approved by City Council December 17, 2007. Thank you. NG:dr c: Karina Rueda Resolution File No. 9497 Risk Management Inter Office Memorandum To: Jeff Harrison, City Attorney Fr: Willard G. Yamaguchi, Chief Deputy City Attomey/Risk Manager Re: MetLife Contract Amendment Re Domestic Partners Da: December 15, 2008 Risk Management obtained a contract amendment to define "Domestic Partners." Previously, Domestic Partner included opposite sex relationships. Recently, the city council defined the relationship as same sex partners that registered with the Secretary of State, same sex partnerships that entered into a valid union other than marriage as defined by California law, or opposite sex relationships over the age of 62 years. It is recommended that the City Council ratify said amendment. cc: Nelly Giron, City Clerk Lehr, Legal Secretary Attachment Judy MetL e Metropolitan Life Insurance Company 200 Park Avenue, New York, New York 10166-0188 CERTIFICATE RIDER Group Policy No.: KM 05723438-G Employer: City of Vernon Effective Date: January 01, 2008 The certificate is changed as follows: Under DEFINITIONS OF CERTAIN TERMS USED HEREIN, the definition of "Domestic Partner" is replaced with the following: Domestic Partner" means each of two people who are: • of the same sex; and one of whom is an employee of the Policyholder, and who meet the requirements of California law for establishment of a domestic partnership and have registered as domestic partners with the California Secretary of State; or of the same sex; and one of whom is an employee of the Policyholder, and have entered into a legal union, other than a marriage, that was validly formed in another jurisdiction, and that is substantially equivalent to a domestic partnership as defined under California law, regardless of whether the legal union bears the name domestic partnership; or • of the opposite sex, and at least one person is over 62 years of age and is eligible for old -age Social Security benefits, and one of whom is an employee of the Policyholder, and who meet the requirements of California law for establishment of a domestic partnership and have registered as domestic partners with the California Secretary of State. This rider is to be attached to and made a part of the Certificate. Form G.8480 Dental Insurance All Active Full -Time Employees and Retired Employees RV 05/07/2008 J MetLife' Metropolitan Life Insurance Company 200 Park Avenue, New York, New York 10166-0188 POLICY AMENDMENT Group Policy No.: KM 05723438-G Policyholder: City of Vernon Effective Date: January 01, 2008 Metropolitan Life Insurance Company ("MetLife"), a stock company, issues this amendment to change the following: Add to Exhibit 2 of the policy the attached certificate form as: Certificate Form Applies To Effective Date Form G.8480 All Active Full -Time Employees and January 01, 2008 Retired Employees This amendment is to be attached to and made a part of the policy. This amendment is subject to the terms and provisions of the policy. To be completed by the Policyholder: Sinned at: Vernon CA pate: May 21, 2008 WILLARD G. YAMAGUCHI, RISK MANAGER (Print Name and Title of Legal Representative) KARINA RUEDA (Print Name of Witness) To be completed by Metropolitan Life Insurance Company: Signed at: Kansas City, Missouri Date:05/07/2008 (City) (State) (Signature of Authorized MetLife Representative) PA99 C. Robert Henrikson Chairman of the Board, President. and Chief Executive Officer Dental Insurance RV 05/07/2008 « i NOV s � �azf� Me ife Metropolitan Life Insurance Company S K MA A EI HENT KEPT 200 Park Avenue, New York, New York 10166-0188 POLICY AMENDMENT Group Policy No.: KM 05723438-G Policyholder: City of Vernon Effective Date: November 01, 2008 Metropolitan Life Insurance Company ("MetLife"), a stock company, issues this amendment to change the following: Add to Exhibit 2 of the policy the attached certificate form as: Certificate Form Applies To Effective Date Form G.8480 All Active Full Time Employees November 01, 2008 Form G.8480 Retired Employees November 01, 2008 This amendment is to be attached to and made a part of the policy. This amendment is subject to the terms and provisions of the policy. To be completed by the Policyholder: Date: MARCH 3, 2009 WILLARD G. YAMAGUCHI (Print Name and Title of Legal Representative) KARINA RUEDA (Print Name of Witness) To be completed by Metropolitan Life Insurance Company: Signed at: Kansas City, Missouri Date:11/07/2008 (City) (State) (Signature of Authorized MetLife Representative) PA99 C. Robert Henrikson Chairman of the Board, President and Chief Executive Officer Dental Insurance RV 11/07/2008 Me{tLi f e Metropolitan Life Insurance Company 200 Park Avenue, New York, New York 10166-0188 CERTIFICATE RIDER Group Policy No.: KM 05723438-G .Employer: City of Vernon Effective Date: November 01, 2008 The certificate is changed as follows: 1. The provision entitled, ELIGIBILITY FOR BENEFITS, is changed as follows: ,CITY AT FY, 3N!.v RISK MA C NAGEMEN For All Active Full Time Employees Personal Benefits Eligibility Date If you are an Employee on November 01, 2008, that is your Personal Benefits Eligibility Date. If you become an Employee after November0l, 2008, your Personal Benefits Eligibility Date is the first day of the month coincident with or next following the date you become an Employee of the Employer. Dependent Benefits Eligibility Date Your Dependent Benefits Eligibility Date is the later of your Personal Benefits Eligibility Date and the date you first acquire a Dependent. 2. The provision entitled, WHEN BENEFITS END, is changed as follows: A. All of your benefits will end on the last day of the calendar month in which your employment ends. Your employment ends when you cease Active Work as an Employee. However, for the purpose of benefits, the Employer may deem your employment to continue for certain absences. See CONDITIONS UNDER WHICH YOUR ACTIVE WORK IS DEEMED TO CONTINUE. B. If This Plan ends in whole or in part, your benefits which are affected will end. C. Your Dependent Benefits will end on the earlier of: 1. the last day of the month that the Dependent ceases to be your Dependent; or 2. the date of your death. Form G.8480 Dental Insurance All Active Full Time Employees RV 11 /07/2008 The end of any type of benefits on account of a Covered Person will not affect a claim which is incurred before those benefits ended. The Dental Expense Benefits for a Covered Person may be continued in accordance with the Federal law called COBRA. See the pages entitled NOTICE OF YOUR RIGHT AND YOUR DEPENDENTS' RIGHT TO CONTINUE DENTAL BENEFITS, This rider is to be attached to and made a part of the Certificate. Form G.8480 Dental Insurance All Active Full Time Employees RV 11/07/2008 M 5 Mehl ife' Metropolitan Life Insurance Company 200 Park Avenue, New York, New York 10166-0188 CERTIFICATE RIDER Group Policy No.: KM 05723438-G Employer: City of Vernon Effective Date: November 01, 2008 The certificate is changed as follows: 1. The provision entitled, ELIGIBILITY FOR BENEFITS, is changed as follows: For Retired Employees Personal Benefits Eligibility Date i NrJV;' MI If you are a Retired Employee on November 01, 2008, that is your Personal Benefits Eligibility Date. If you become a Retired Employee after November 01, 2008, your Personal Benefits Eligibility Date is the first day of the month coincident with or next following the date you become a Retired Employee of the Employer. Dependent Benefits Eligibility Date Your Dependent Benefits Eligibility Date is the later of your Personal Benefits Eligibility Date and the date you first acquire a Dependent. 2. The provision entitled, WHEN BENEFITS END, is changed as follows: A. All of your benefits will end on the last day of the calendar month in which you are no longer an eligible Retired Employee. B. If This Plan ends in whole or in part, your benefits which are affected will end. C. Your Dependent Benefits will end on the earlier of: 1. the last day of the month that the Dependent ceases to be your Dependent; or 2. the date of your death. Form G.8480 Dental Insurance Retired Employees RV 11 /07/2008 D. If a Covered Person does not make a payment which is required by the Employer to the cost of any benefits, those benefits will end; they will end on the last day of the period for which a payment required by the Employer was made. The end of any type of benefits on account of a Covered Person will not affect a claim which is incurred before those benefits ended. The Dental Expense Benefits for a Covered Person may be continued in accordance with the Federal law called COBRA. See the pages entitled NOTICE OF YOUR RIGHT AND YOUR DEPENDENTS, RIGHT TO CONTINUE DENTAL BENEFITS. This rider is to be attached to and made a part of the Certificate. Form G.8480 Dental Insurance Retired Employees RV 11 /07/2008 Mettife Metropolitan Life Insurance Company 200 Park Avenue, New York, New York 10166-0188 POLICY AMENDMENT Group Policy No.: KM 05723438-G Policyholder: City of Vernon Effective Date: January 01, 2008 Metropolitan Life Insurance Company ("MetLife"), a stock company, issues this amendment to change the following: Add to Exhibit 2 of the policy the attached certificate form as: Certificate Form Applies To Effective Date Form G.8480 All Active Full -Time Employees and January 01, 2008 Retired Employees This amendment is to be attached to and made a part of the policy. This amendment is subject to the terms and provisions of the policy. To be completed by the Policyholder: Signed at: Vernon CA Date: May 21, 2008 WILLARD G. YAMAGUCHI, RISK MANAGER (Print Name and Title of Legal Representative) KARINA RUEDA (Print Name of Witness) To be completed by Metropolitan Life Insurance Company: Signed at: Kansas City, Missouri Date:05/07/2008 (City) (State) (Signature of Authorized MetLife Representative) PA99 C. Robert Henrikson Chairman of the Board, President and Chief Executive Officer Dental Insurance RV 05/07/2008 Meftife Metropolitan Life Insurance Company 200 Park Avenue, New York, New York 10166-0188 CERTIFICATE RIDER Group Policy No.: KM 05723438-G Employer: City of Vernon Effective Date: January 01, 2008 The certificate is changed as follows: Under DEFINITIONS OF CERTAIN TERMS USED HEREIN, the definition of "Domestic Partner" is replaced with the following: Domestic Partner" means each of two people who are: • of the same sex; and one of whom is an employee of the Policyholder, and who meet the requirements of California law for establishment of a domestic partnership and have registered as domestic partners with the California Secretary of State; or • of the same sex; and one of whom is an employee of the Policyholder, and have entered into a legal union, other than a marriage, that was validly formed in another jurisdiction, and that is substantially equivalent to a domestic partnership as defined under California law, regardless of whether the legal union bears the name domestic partnership; or • of the opposite sex, and at least one person is over 62 years of age and is eligible for old -age Social Security benefits, and one of whom is an employee of the Policyholder, and who meet the requirements of California law for establishment of a domestic partnership and have registered as domestic partners with the California Secretary of State. This rider is to be attached to and made a part of the Certificate. Form G.8480 Dental Insurance All Active Full -Time Employees and Retired Employees RV 05/07/2008