Resolution No. 2013-091A RESOLUTION OF THE CITY COUNCIL OF THE CITY OF
VERNON APPROVING THE PAYMENT OF: MEDICAL AND .DENTAL
INSURANCE PREMIUMS FOR FULL TIME EMPLOYEES AND .
RETIREES UNDER THE AGE.OF 65 AND LIFE INSURANCE
PREMIUMS FOR FULL TIME EMPLOYEES FOR THE 2014
CALENDAR YEAR
WHEREAS,,the City Council of the City of Vernon .in prior
fiscal years has approved for each fiscal` year the,City's payment of.
.premiums for insurance for medical, dental, and life, benefits for
full time regular employees and their dependents; and
WHEREAS, on November 6, 2012, the City Council of the City
of -Vernon adopted Resolution No. 2012-20.5, to continue paying the.
premium for medical, dental and life benefits for full time regular
employees for calendar year 2013; and
WHEREAS on October 15, 2013, the City Council considered the
City's payment of medical and dental insurance premiums for full time
employees and retirees under the age of 65, the funding.of the Health
Savings•Account ("HSA"), and life insurance premiums for full time
employees, applicable for the 2014 calendar year; and
WHEREAS, by memorandum dated October 15, 2013, the Director
of Human Resources has requested (1) the approval of the payment of
medical, dental and life insurance premiums for calendar year 2014;
(2) authorization to change from Aetna medical and dental insurance
benefit packages to Anthem Blue Cross medical and MetLife dental for
full time employees and retirees under the age of 65, at an
approximate annual premium cost of $3,537,284, and $186,000 for HSA
contributions for full time employees enrolled under the HSA PPO
Medical, plan and (3) authorization to change, the Life Insurance
100913938
carrier from Lincoln Financial to Mutual of Omaha, at an approximate
annual premium cost of $5,578 for Life Insurance premiums for full
time employees; and
WHEREAS, the City Council of the City of Vernon wishes to
adopt its policy applicable to the 2014 calendar year, only,
respecting payment of premiums for the City's insurance for medical,
dental and life benefits for employees, and the funding of the Health
Savings Account, and to declare that such benefits are not vested
.:rights and will expire at the conclusion of the calendar year unless
authorized and approved by the City Council for any subsequent
calendar year.
NOW, THEREFORE, BE IT RESOLVED BY THE CITY COUNCIL OF THE
CITY OF VERNON AS FOLLOWS:
SECTION 1: The City Council of the City of Vernon.hereby
finds and determines that the above recitals are true and correct.
SECTION 2: The City Council of the City of Vernon finds
that this action is exempt under the Californa.Environmental Quality
Act (CEQA), in accordance with Section 15061(b)(3);.the general rule
that CEQA only applies to projects that may have an effect on the
environment
SECTION 3: The City Council of the City of Vernon hereby
approves the change in provider for medical and dental insurance
benefit packages to Anthem B1ue.Cross medical and MetLife dental and
the change of Life Insurance carrier to Mutual of Omaha.
SECTION 4: The City Council of the City of Vernon hereby
adopts the following policy and declares that such benefits are not
vested rights: The City will contribute up, to $1'050 a month towards
City -sponsored medical and dental premiums for miscellaneous employees
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enrolled in an HMO Medical Plan, and contribute up to $800 a month
towards City -sponsored medical and dental premiums for those employees
enrolled in a PPO Medical Plan. Pursuant to their respective
Memoranda of Understanding, the City will contribute up to $1,100 a
month towards City -sponsored medical and dental premiums for safety
employees enrolled in an HMO Medical Plan, and contribute up to $850 a
month towards City -sponsored medical and dental premiums for those
safety employees enrolled in a PPO Medical Plan. The City will pay
the insurance premium up to said amounts for the medical and dental.
benefits as such benefits are in effect as of January 1, 2014, and
will continue to pay the insurance premium for life benefit, for all
full time regular employees.
SECTION 5: The City will fund $1,500 on January 1, 2014,
and $500, each, in March, June and September for those full time
employees enrolled in the City -sponsored Health Savings Account
("HSA") PPO Medical Plan.
SECTION 6: The City's agreement to pay said premiums
provided for above, shall not create or ripen into a vested right for
any employee to any such medical, dental, or life, benefit beyond
December 31, 2014.
3 - 100913938
SECTION'7: The Interim City Clerk, or Deputy City Clerk, of
the City of Vernon shall certify to the passage, approval and adoption
of this resolution, and the Interim City Clerk, or Deputy City Clerk,
of the City of Vernon shall cause this resolution and the Interim City
Clerk's, or Deputy City Clerk's, certification to be.entered in the
File of Resolutions of the Council of this City.
APPROVED AND ADOPTED this 151h day of October, 2013.
Name: ghael McCormick
Title: Mayor / -
Dante Reed
Interim City Clerk / Deputy City Clerk
APPROVED AS TO FORM:
Zaynah M up sa, Deputy City Attorney
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STATE OF CALIFORNIA )
ss
COUNTY OF LOS ANGELES )
I Dario Reed Interim City Clerk Hof
the City.of Vernon,. do hereby certify that the foregoing.Resolution,
being Resolution No. 2013-91, was 'duly passed, approved and adopted by
the City Council of the City of Vernon at,a regular meeting of the City
Councilduly held on Tuesday, October 15, 2013, and thereafter was duly
signed by the Mayor Mayor Pro-Tem of the City of Vernon.
Executed this day .of October, 2013, at Vernon, California.
A I � AA
5 _ - - 100913938
%1*110)IN'7TKY11yyCy11
11►f11111"TO Wycol Dlu111uC13t"O11ilh1
DATE: October 22, 2013
TO: Teresa McAllister, Director of Human Resources �,
FROM: Deborah Juarez, Records Management Assistant%/
RE: Resolution No. 2013-91— A Resolution of the City Council of the City of Vernon
Approving the Payment of Medical and Dental Insurance Premiums for Full Time
Employees and Retirees Under the Age of 65 and Life Insurance Premiums for Full Time
Employees for the 2014 Calendar Year
Transmitted herewith is a copy of Resolution No. 2013-91 referenced above, which was approved by
City Council on October 15, 2013.
Thank you.
Attachment
c: Raquel Franco
Karina Rueda
Resolution No. 2013-91
RECEIVED
. 0 OCT 0 9 2013
RECEIVED CITY ADMINISTRATION
OCT 0 9 2013 STAFF REPORT
CITY CLERK'S OFFICE HUMAN RESOURCES DEPARTMENT 19
DATE: October 15, 2013
TO: Honorable Mayor Pro'Tem and City Council
FROM: Teresa McAllister, Director of Human Resources
RE: A Resolution of the City Council of the City of Vernon approving the
payment of Medical, Dental, and Life Insurance Premiums for Full Time
Employees and Retiree., under the Age of 65 for the 2014 Calendar Year
Recommendation
It is recommended that the City Council:
1) Find that approval of the proposed resolution authorizing the payment of the 2014
medical, dental and life insurance premiums and change from Aetna medical and dental
insurance benefit packages to Anthem Blue Cross and MetLife dental insurance plans is
exempt under the California Environmental Quality Act (CEQA) in accordance with
Section 15061(b)(3), the general rule that CEQA only applies to projects that may have
an effect on the environment.
2) Approve and adopt the attached resolution authorizing the payment of medical, dental
and life insurance premiums for calendar year 2014 and the change from Aetna medical
and dental insurance benefit packages to Anthem Blue Cross and MetLife dental
insurance plans for full time employees and retirees under the age of 65 at an
approximate annual premium cost of $3,537,284 for medical and dental premiums, and
$186,000 for HSA contributions for employees enrolled under the HSA PPO Medical
plan. The resolution also .proposes to change the Life Insurance carrier from Lincoln
Financial to Mutual of Omaha; the approximate annual cost for Life Insurance premiums
for full time employees is $5,578.
Background
Alliant Insurance, the City's insurance broker for medical benefits, solicited quotes from Aetna,
Vernon's current medical benefit provider, Anthem Blue Cross, Blue Shield and Cigna. Quotes
were received from Aetna, Anthem Blue Cross, and Blue Shield. Cigna declined to submit a
quote.
Upon review of said quotes and plan comparisons by City staff and employee representatives of
the City of Vernon Health Insurance Committee, it is recommended, that the City of Vernon
change its medical plan for calendar year 2014 to Anthem Blue Cross Marketplace, at an
approximate annual premium cost of $3,202,233 for medical based upon current employee
enrollment figures. This cost reflects Alliant's overall negotiated rate decrease of 3.91% in the
City's current medical plan coverage. Anthem Marketplace affords employees the freedom of
choice between six (6) healthcare coverage options that best meet their financial needs and the
health insurance needs of themselves and their families.
Anthem Blue Cross Marketplace will offer six medical plans designed for employees to choose
from. They are Anthem Marketplace:
• Value Plan — (Low HMO)
• Classic HMO Plan (Medium HMO)
• Premier HMO Plan (High HMO)
• Premier PPO
• Classic PPO
• HDHP (HSA High deductible PPO)
In addition, Alliant Insurance solicited quotes for dental plan coverage from Delta Dental, Cigna,
Guardian, MetLife, Mutual of Omaha and Aetna the City's current dental benefit provider.
Quotes were received from Delta Dental, MetLife and Aetna. All others declined.
Upon review of said quotes and plan comparisons by City staff and the Health Insurance
Committee, it is recommended that the City change dental plans to MetLife for calendar year
2014, at an approximate annual premium cost of $335,051 based upon current employee
`enrollment figures. This cost reflects Alliant's overall negotiated rate decrease of 3.5% in the
City's current dental plan coverage. MetLife dental Insurance will offer two dental plans
designed for employees to choose from. They are:
• HMO Dental
• PPO Dental
In an effort to continue seeking opportunities to reduce the cost of benefits, City staff also
requested that Alliant solicit quotes on the ancillary benefits. As a result, staff recommends
changing the City of Vernon life insurance premium coverage from Lincoln Financial to Mutual
of Omaha. The approximate annual premium cost of $5,578 for life insurance reflects Alliant's
overall negotiated rate decrease of 33.3%.
Per Resolution 2012-205, the City contributes up to $1,050 a month towards City -sponsored
medical and dental premiums for miscellaneous employees enrolled in an HMO Plan, and up to
$800 a month towards City -sponsored medical and dental premiums for those employees
enrolled in a PPO Plan. Based on the current enrollment of full time employees, the approximate
annual cost to the City is $1,170,085. In addition, the City contributes $3,000.00 per employee
per year into a Health Savings Account for employees enrolled under the City -sponsored HSA
PPO Medical Plan to help offset the high deductible associated with the HSA plan. Based upon
the current enrollment of employees under this plan, the approximate annual cost to the City is
$186,000 annually.
Per Resolutions 2012-95 and 2012-94, approving the Memoranda of Understanding with the
Vernon Police Officers Benefit Association and the Vernon Firemen's Association, respectively,
the City will contribute up to $1,100 a month for employees and eligible dependents towards
City -sponsored medical and dental premiums for employees enrolled in a HMO Plan and up to
$850 per month for employees and eligible dependents enrolled in the PPO plan. Based upon the
current enrollment of safety employees, the approximate cost to the City is $1,206,465.
Additionally, certain categories of retirees qualify for City -paid medical premiums or subsidized
medical premiums. Based on the current enrollment of retirees under the age of 65, the
approximate cost to the City is $439,243.
Fiscal Impact
The total estimated cost for medical, dental, and life insurance premiums for calendar year 2014
is $3,007,371. Sufficient funds have been budgeted by each Department for this expenditure for
fiscal year 2013-2014.
CITY CLERK'S OFFICE
INTEROFFICE MEMORANDUM
DATE: January 14, 2014
TO: Teresa McAllister, Director of Human Resourcesi1
FROM: Deborah Juarez, Records Management Assistantl
RE: Anthem Blue Cross Medical Insurance Master Services Agreement Approved through
Resolution No. 2013-91— A Resolution of the City Council of the City of Vernon
Approving the Payment of Medical and Dental Insurance Premiums for Full Time
Employees and Retirees Under the Age of 65 and Life Insurance Premiums for Full Time
Employees for the 2014 Calendar Year
For your transmittal, please find attached one copy of the fully executed Anthem Blue Cross Medical
Agreement approved through Resolution No. 2013-91 referenced above and approved by City Council
on October 15, 2013.
Thank you.
Attachment
c: Karin Rueda
Resolution No. 2013-91
Agreement No. 13-110
CONTRACT/AMENDMENT SIGNATURE ROUTING FORM
CONTRACTOR: Blue Cross Anthem
CONTRACT PURPOSE: Citywide Medical and Dental Benefits
CONTRACT IS: ❑ FEDERAL ❑ PREVAILING WAGE ❑ COMPETIVE SELECTION & NOTICED RFP
❑ COMPETITIVE BID & NOTICED INVITATION TO BID
❑ EXEMPT FROM COMPETITIVE PROCESS (APPROVAL ATTACHED)
�,SERVICES O MATERIALS ❑ BUDGETED ❑ NOT BUDGETED
TOTAL CONTRACT VALUE: 5� Charge Acct. No(s) VW104,P
Amendment Value $ ❑ Contract is an Amendment to Contract No. (if Applicable)
RESPONSIBLE DEPARTMENT PERSON: ae& PHONE: .1V
AUTHORIZATION: XApproved by Council on
(Check One) Resolution NP (if applicable)
❑ Approved by City Administrator on
Note: Attach supporting documentation
Amendment Approved by (if applicable)
ROUTING SEQUENCE: (Please Follow In Order — Do not use N/A) Initials Date
(1) Responsible Department Person
Checks substance of contract and assembles two (2) copies of
Contract, insurance & bond documents, certifies compliance
With Competitive Bidding and Purchasing Ordinance Cv
(2) Liability and Claims
Approves insurance and sureties, if bonds required 1-7-Al
(3) Finance (Purchasing)
Checks compliance with Competitive Bidding &Living Wage Ordinances
And reflected in current budget
(4) City Attorney ' I
Approves contract as to form, verifies bonds and insurance included
(5) City Signatory
Signs all copies on behalf of City
(6) City Clerk
Attests signatures, numbers, files contract, insurance and bonds, and gpw
transmits duplicate original to contractor
Rev. 425/13
Company: City of Vernon
Effective Date: I/l/10
Renewal Date: 1/1/15
MASTER SERVICES AGREEMENT
Private Exchange Services
This Master Services Agreement (the "Agreement") is entered into on the Effective Date set forth above by and between Anthem Blue Cross Life
and Health Insurance Company ("Anthem") and the Company named above.
RECITALS
A. Anthem assists employees and their dependents in selecting group health plan coverage options that best match their
lifestyles, risk tolerance and needs,
B. Company desires to establish an account -based approach to employer -sponsored health care.
Now theret'om, in consideration of the mutual promises set forth in this Agreement, and other consideration, the exchange, receipt and
sufficiency of wWch is hereby acknowledged, the patties agree as follows:
ARTICLE 1: Definitions
As used herein, the following capitalized terms shall have the meanings indicated:
"Code" means the Internal Revenue Code of 1986, as amended, and it's implementing regulations.
"Private Exchange Services" shall mean services and systems provided by Anthem, including the web portal, platform, decision support
systems, and online and telephonic services, to assist Participants in the selection of health plan coverage options.
"ERISA" means the Employee Retirement Income Security Act, 29 U.S.C. § 1001 et seq., as amended, and its implementing regulations.
"Health Reimbursement Arrangement' or"HRA" means a self -funded medical reimbursement plan under Code § 105 to be used solely for
the payment of health insurance premiums.
"Member^ means a Participant, a Participant's spouse or dependent, or other eligible person who is covered under the Plan.
"Participant" means an employee or retiree of the Company who is eligible for and enrolled in the Company's group health plan.
"Pion" means the HRA, which is not offered as part of a cafeteria plan and may not be provided pursuant to salary reduction election.
"Plan Administrator" means the person or other such entity, as stated in the Plan Document, which is responsible for the administration of the
Plan. The Plan Administrator is the Plan's named fiduciary, as that term is used in ERISA
"Plan Document" means the document(s) provided to Participants establishing and setting forth the terms and conditions of this Plan and the
Plan's coverage. The Plan Document is also intended to be the summary plan description as required by and described in ERISA for components
subject to ERISA.
ARTICLE Ih Services and Scope of Work
2A Private Exchange Services. Anthem shall provide the Private Exchange Services either directly or through one or more
designated Subcontractors to help Participants through personalized decision support systems designed to match Participants with appropriate
health plan coverage.
2.2 Anthem, or an affiliate of Anthem, is the insurer of a group health plan sponsored by Company under separate policies or
contracts with the Company. Anthem's responsibilities under this Agreement are independent of the provision of coverage under such policies or
contracts.
ARTICLE U : Term and Termination
3.1 Term. This Agreement will commence on the Effective Date and will continue until the Renewal Date set forth above,
unless earlier terminated as provided herein (the "Initial Tenn").
3.2 Renewal Terms. Upon the expiration of the Initial Term, this Agreement may be renewed for successive additional (one
(I)] year periods unless earlier terminated as provided herein. Each such period following the Initial Term is referred to herein as a "Renewal
Tema' The Parties may agree to changes to the Agreement for any Renewal Tam, including changes to Service Fees, at any time before thirty
(30) days prior to the beginning of the Renewal Tam. Either Party may terminate this Agreement at the and of the Initial Term or any Renewal
Tenn by giving 30 days prior written notice to the other.
3.3 Termination for Cause.
a. This Agreement automatically terminates, without further notice or action, if Company fails to pay any amount
due under this Agreement within 7 days of the date of Anthem's notice to Company of a delinquent amount owed. Such termination shall be
effective as of the last period for which full payment was made.
b. This Agreement automatically terminates, without further notice or action, if all of the group policies or
contracts issued by Anthem and/or an Anthem affiliate to Company terminate.
C. Except as provided in Sections 3.3.a. and 3.3.b. of this Agreement, either Party may terminate this Agreement
upon 30 days' prior written notice to the ddmer stating the effective date of termination in the event the other Party commits a material breach of
any obligation or covenant under this Agreement and the breaching Party fails to cure such breach within thirty (30) days following receipt of
notice of such breach from the non -breaching Party indicating the specific term or terms of the Agreement which have been breached and
describing, in reasonable detail, the event or events which have caused the breach.
3.4. Waive. Any waiver of a breach of this Agmemem will not constitute a waiver of any subsequent breach.
ARTICLE IV: Pees
The fees due Anthem for the performance of services are set forth in Exhibit A. All fees payable to Anthem hereunder shall be
invoiced by Anthem, and Company shall pay all fees due within thirty (30) days of the date of the invoice.
ARTICLE V: Obligations of Anthem Regarding Private Exchange Services
5.1 Group Health Plan. Anthem will assist Participants in choosing among the health plan options made available by
Company. . Anthem will make reasonable efforts to educate and assist Participants in selecting the heahh plan option that best fits their needs,
but does not guarantee that any option selected by an individual will provide the greatest benefits or lowest cost under the particular facts and
circumstances. Anthem will make reasonable efforts to accurately describe the health plan benefits, rights and features, but does not guarantee
that every communication will be correct or complete. Anthem will include a disclaimer in its written materials to Participants that information
provided by Anthem will not modify, or amend the terms of the group health plan or summary plan description.
5.2 Not a fiduciary. Company acknowledges and agrees that, under this Agmement, neither Anthem nor any subcontractors
performing services on Anthem's behalf am acting as a fiduciary of any employee welfare benefit plan. Under this Agreement, Anthem does not
exercise any discretionary authority or control regarding (i) management or administration of Company's welfare benefit plans, or (ii) funding or
disposition of assets under any such plan.
5.3 Enrollment assistance. Anthem will provide standard data and formatting specifications to Company to transmit and
receive data files to and from Anthem.
5.4 Customer Service. Anthem will answer questions from Participants regarding Participant website usage and Private
Exchange Services.
5.5 Website. Anthem will provide access to a website, that shall allow Participants online access to Private Exchange Services,
5.6 Reports. Anthem will provide reports listed and in the manner described in Exhibit B.
ARTICLE VI: Obligations of Company Regarding Private Exchange Services
6.1 Enrollment and Eligibility. Company shall provide enrollment and eligibility data to Anthem in an electronic format
consistent with standard data and formatting specifications provided by Anthem. Company shall provide any other information that Anthem may
need to properly administer Private Exchange Services. Company shall notify Anthem on a monthly basis of all changes in its employees eligible
to participate in the Plan.
6.2 Regulatory Compliance.
a. ERISA. If the Plan is governed by ERISA, Company represents that it is the plan sponsor of the Plan ea
identified in the Plan Document. Company and Plan Administrator shall comply, and ensure that the Plan complies with ERISA and all
applicable law and regulations. Specifically, and in no way limiting the foregoing, Company and Plan Administrator shag be solely responsible
for compliance with all Internal Revenue Code requirements related to the administration of the Plan and activities undertaken by Anthem at The
direction of the Plan Administrator. Anthem will obtain and maintain any licenses or regulatory approvals necessary, for it to perform its services
under this Agreement.
b. COBRA. All duties of the Company and Plan Administrator, including, but not limited to, notifying Members
regarding continuation rights and premium billing and collection, remain the responsibility of Company and Plan Administrator.
G. Election Changes. Company is solely responsible for determining if election changes are allowed in accordance
with the requirements of Code § 125.
d. Compliance with HIPAA Privacy and Security Regulations. Compliance with any and all applicable provisions
of the privacy and security regulations issued pursuant to HIPAA shall be the responsibility of the Plan. For purposes of the Plan's compliance
with provisions of HIPAA relating to business associate contracting, the parties agree to abide by the provisions of Exhibit C — Business
Associate Agreement which by reference is incorporated herein.
e. The Code. Company has sole responsibility for compliance with the Code; including any plan design choices
that may affect tax treatment of the HRA.
ARTICLE VIL• General Terms and Conditions
7.1 Regulations. The Parties will perform their obligations under the Agreement in compliance in all material respects with
applicable regulations. Provided, Anthem does not assume responsibility for compliance with regulations that apply to Company, and Company
does not assume responsibility for compliance with regulations that apply to Anthem.
7.2 No legal or Tax Advice. Anthem is not an attorney, tax advisor or investment advisor and does not mender legal, tax or
investment advice in connection with the creation, adoption or operation of any employee benefit plan Company will seek the advice of counsel,
as needed, as to matters that might arise in connection with design, adoption or operation of the Plan.
7.3 Intellectual Property.
a. Grant of License. Company acknowledges that Anthem will provide Participant a namransfeable, limited right,
without right of sublicense, to access and use Anthem's hosted system comprised of a web portal ("Web Portal") from which a Participant can
use the Private Exchange Services, and other software, hardware and systems (including all updates provided by Anthem), as well as any
documentation famished by Anthem (collectively, "System"). Such access and use shall be via the Internet, solely for personal use by
Participants. Anthem auditor its licensors reserve all rights in and to the System, System data, and other services not expressly granted to
Participants separately (collectively, "Intellectual Property"). Company shall have no right to, and shall not permit any third parry to (except for
Participants who receive permission from Anthem separately): (i) use or access the Intellectual Property for administrative or any other purposes,
including without limitation use for the benefit of any third patty; or (ii) reproduce, publicly display, publicly perform, download, modify, create
derivative works of or distribute, troarofa or assign the Intellectual Property, in whole or in part, or attempt to reverse engineer, decompile,
disassemble, or access the source code for, the Intellectual Property or any component thereof. Company acknowledges that the Intellectual
Property contains copyrighted and proprietary products and materials of Anthem and its licensors.
b. Right to Terminate Access. Arnhem reserves the right to terminate any individual's access to and use of the
System in the event such individual breaches any of the terns and conditions of use thereof.
C. Not a Work for Hire. Anthem and Company agree that this Agreement will transfer no right, title and interest
from Anthem to Company and that Anthem and its licensors will retain all right, title and interest in and to the Intel leetual Property and any
derivative works thereof whether created by Anthem or Company orjointly by the Parties during the term or within one year after the expiration
or termination of this Agreement.
7.4 Survival. The provisions of Section 7.3 shall survive the termination of this Agreement.
ARTICLE VIII: Indemnification
8.1 Indemnification by Anthem
a. Subject to the terms and conditions of this Section 8.1, Anthem will indemnify, defend and hold harmless
Company, its directors, oRicers, employees and agents, from and against any and all damages, claims, losses, liabilities, judgments and expenses,
including but not limited to reasonable attorneys fees, court costs and otter damages and expenses arising out Anthem's breach of this Agreement
or any applicable Exhibit, breach of applicable laws, willful misconduct, criminal conduct, reckless acts or fraud.
b. Anthem will farther indemnify and defend any third party action brought against Company to the extent that it
is based on a claim that the System, caved within the scope of the license granted to each employee or dependent, infringes or misappropriates any
valid United States patent, trademark, trade secret or copyright, provided that Company notifies Anthem in writing immediately upon Company's
receipt of the claim, and Company provides Anthem with the assistance, information, and authority reasonably necessary to perform the defense.
Reasonable out-of-pocket expenses incurred by Company in providing such assistance shall be reimbursed by Anthem. Anthem shall have the
right to control the defense and settlement of all such claims, lawsuits and other proceedings. In no event shall Company settle any such claim,
lawsuit, orproceeding without Anthem's prior written approval.
C. Anthem shall have no liability under this Section 8.1 for any claim based on or relating to: (i) Company Marks
or any third party component in the System; (ii) any misuse of the System; or (iii) any combination of the System with other software or materials
if such infringement would have been avoided by use of the System alone.
d. If a third party infringement claim is sustained in a final judgment from which no further appeal is taken or
possible, or if an employee or dependent's use of the System is enjoined by a court, then Anthem may in its sole election and at its expense either:
(i) procure for the employee or dependent the right to continue to use the infringing materials pursuant to this Agreement; (ii) replace or modify
the infringing materials to make them non -infringing but functionally equivalent; or (iii) terminate this Agreement. The foregoing obligations in
this Section 8.1 state the entire liability of Anthem and the exclusive remedy of Company with respect to any actual or alleged infringement of
any intellectual property rights under this Agreement.
9.2 Indemnification by Company. Except to the extent covered in Section 8.1, Company will indemnify, defend and hold
harmless Anthem, its directors, officers, employees and agents, from and against any and all damages, claims, losses, liabilities, judgments and
expesev, including but not limited to reasonable attorneys fees, court costs and other damages and expenses arising out of Company's breach of
this Agreement or any applicable Exhibit, breach of applicable laws, willful misconduct, criminal conduct, reckless acts or fraud.
8.3 Indemnification Standards. The acts and omissions of the officers, directors, employees, agents, assigns, successors, and
affiliates (and the respective officers, directors, employees, agents, and assigns and any of the preceding) of an indemnifying party will be
deemed to be the acts and omissions of the indemnifying party, and the indemnified party will include the applicable party and its affiliates and
their respective officers, directors, employees, agents, and assigns.
ARTICLE IX: Miscellaneous Provisions
9.1 Notice. At notices, demands, requests, or other communications pursuant to this Agreement shall be in writing and shag
be hand -delivered or mailed first class, postage prepaid, certified or registered mail to the last (mown address of the receiving party. All notices,
demands, requests, or other communication handdelivered or mailed in accordance with this subsection shall be effective as of the date hand -
delivered or mailed.
9.2 Force Majeure. If any Party is delayed or prevented from fulfilling its obligations under this Agreement by Force
Majeure, said Part will not be liable under this Agreement for said delay or failure. "Force Majeure' means any carve beyond the reasonable
control of a Party, including but not limited to acts of God, civil or military disruption, terrorism, disease epidemic, fire, flood, riot, war, or
inability due to the aforementioned cause to obtain necessary labor, materials or facilities.
9.3 Goveming Law. The validity of this Agreement, the interpretation of the rights and duties of the Parties hereunder and
the construction of the terns hereof will be governed in accordance with the laws of the State of California, excluding its choice of law principles
which would cause the laws of another state to apply.
9.4 Severabitty. If any part of this Agreement should be held to be void or unenforceable, such part will be treated as
severable, leaving valid the remainder of this Agreement notwithstanding the part or parts found void or unenforceable.
9.5 Complete Agreement. This Agreement and its Exhibits constitute the complete understanding of the Parties and
supersedes any and all other agreements, either oral or written, between the Parties with respect to the subject matter hereof. No amendment to
this Agreement or any of its Exhibits will be effective unless in writing and signed by the Parties.
9.6 Captions. The captions or headings of the Articles and other sections and subsections hereof are inserted only as a
matter of convenience and shall have no effect on the meaning of the provisions hereof.
9.7 Independent Contractor. In carrying out its duties heeunder, Anthem shall be an independent contractor with respect to
Company. Neither this Agreement nor the exercise of any of the authority granted to Anthem hereunder shall be deemed to create any
partnership, joint venture, association or other relationship between Company and Anthem.
9.8 No Third Party Eeneficiates. This Agreement is for the sole benefit of the Parties, and there are no third party
beneficiaries to the Agreement, including without limitation, any Employees.
9.9 Cumulation of Remedies; No Waiver. The various rights, options, elections, powers, and remedies of the respective
Parties as provided in this Agreement am in addition to any others that said Parties may be entitled to by law, shall be construed as cumulative,
and no one of them is exclusive of any of the others, or of any right or priority allowed by law. The failure of a Party to mereise any of its rights
or to give any notice with respect to any default by the other Patty or otherwise to insist upon the strict performance of the other Party's
obligations hereunder shall not be deemed a waiver of such Parry's right with respect thereto in the future.
9.10 Assignment and Delegation. Anthem may assign all or any of its rights and responsibilities under this Agreement to any
entity controlling, controlled by or under common control with Anthem. If Anthem assigns all or any of its rights or responsibilities and" this
Agreement, Anthem will notify Plan Administrator in writing of such assignment. Anthem may delegate certain of its obligations under this
Agreement to persons under contract with Anthem. Neither Company nor Plan Administrator shall assign any of their rights and responsibilities
under this Agreement to any person or entity without the prior written consent of Anthem, which consent shall not be unreasonably withheld.
9.11 Independent Corporation. Company, on behalf of itself and its Members, hereby expressly acknowledges its understanding
that this Agreement constitutes a contract solely between Company and Anthem, that Anthem is an independent corporation operating under a
license with the Blue Cross and Blue Shield Association ("BCBSA") permitting Anthem to use the Blue Cross and Blue Shield Service Marks in
(Insert State) and that Anthem is not contracting as the agent of BCBSA. Company further acknowledges and agrees that it has not entered into
this Agreement based upon representations by any person other than Anthem and that no person, entity, or organization other than Anthem shall
be held accountable or liable to it for any of Anthem's obligations to Company created under this Agreement. This paragraph shall not create any
additional obligations whatsoever on the part of Anthem other than those obligations created under other provisions of this Agreement.
9.12 Arbitration.
a. In the event that any dispute, claim, or controversy relating to this Agreement arises between the Parties, the
Parties agree to meet in person and make a good faith effort to resolve the dispute. If the dispute is not resolved following such meeting, and
either Party wishes to pursue the dispute further, that Party shag commence arbitration by riling an arbitration demand with the American
Arbitration Association ("AAA") within 20 days of the meeting. The dispute shall be resolved through arbitration to be heard in Las Angeles,
California unless the Parties agree otherwise.
b. Any dispute subject to arbitration as set forth in this Section 9.12 shall be settled by binding arbitration, except
to the extent that the dispute is required by law to be resolved by a stare or federal regulatory authority. Company shall not have the right to
participate m a member of any clans of claimants pertaining to any dispute subject to arbitration hereunder, nor shall there be any authority for
disputes arising under this Agreement to be arbitrated on a class action basis. Arbitration shall be limited to disputes between the Parties and
cannot be consolidated orjoined with claims of other pmsons or amities who may have similar claims.
c. The Commercial Arbitration Rules of the AAA shall apply, using a 7 member panel of arbitrators. The
arbitration panel shall consist of one arbitrator selected by each Party and the third independent arbitrator who shall be selected and agreed upon
by the first 2 arbitrators. The Parties may also use a single arbitrator provided they mutually agree to do so and mutually agree on the choice of
the arbitrator. The decision of the arbitrator(s) shall be binding. Each Party shag bear its own costs (including attorneys fees) for the
proceedings, and all other costs of the arbitration proceeding shall be shared equally by the Parties, except as may be awarded in the discretion of
the arbitrator(s) in accordance with the arbitration decision (including an award of attorneys' fees). Judgment upon the award rendered by the
arbitmtoi(s) may be entered and enforced by any court of competent jurisdiction.
9.13 Change in Ownership/Control. In the event of a change in ownership or change in control of a Party, that Party's
successor or assign will have the same rights, matter", obligations and liabilities as that Party had prior to the change in ownership or change in
control.
IN WITNESS WHEREOF, this Agreement has been executed by the Parries as of the day and year first above written.
ANTHEM � COMPANY
By: Byxe*�40f
Name: Pam ffby V Name:W. Michael McCormick
Its: i•e ro 1 d e its: Mayor
ATTEST:
ANT EM
B. Ana Barci Dep ty C ilplfClerk
Name: ka*h /PFq' APPROVED TO FORM:
Its: 62erz�Gt/
ZaynaVNj lifoussa, Deputy City Attorney
EXHIBIT A
EXHIBIT A
FEES
Monthly Account Fees
On an on -going basis, Anthem charges a Per -Participant -Per -Month (PPPM) lice for each participant account it administers on behalf of Anthem.
Fees are based on the number of Participants with one or more accounts active on the Bret day of the month, calculated as of the 10e of each
month. Because this fee is based upon the existence of an active account, retroactive changes in enrollment under the health plan will not result
in retroactive additions or retraction of fees.
Anthem's PPPM fee is E
EXHIBIT B
EXHIBIT B
EMPLOYER RF.PORTA
REPORTCATAGORY
REPORT NAME
DESCRIPTION
FREQUENCY
DISTRIBUTION
Plan Administration
Payroll Accounting
Employee enrollment
Monthly
Report is located
Summary
contribution and applicable
on the Bloom
Employer Portal.
payroll deduction balance
Bloom uploads this
information 7 days
before each pay
period as outlined in
the employer set-up
forth. -
The report is then
retrieved manually
by the client (or by
the Broker if access
is granted by the
.
Employer) through
the Admin Portal.
Plan Administration
Enrollment Summary
Employee enrollment status and
Open enrollment
Report is located
on the Bloom
HRA summary -
Period (mid-
Employer Portal.
point and at
Real Time
Clow)
enrollment report.
-
The report is then
retrieved manually
by the client (or by
the Broker if access
is granted by the
Employer) through
the Admin Portal.
EXHIBIT C
Exhibit C
Group Health Plan Business Associate Agreement
This Business Associate Agreement ("Agreement") is made among Anthem ("Business Associate'), and the Group Health Plan ("Plan"), and the
Company ("Employer') named on the signature page of this Agreement.
WITNESSETH AS FOLLOWS:
WHEREAS, Employer has established and maintains a plan of health care benefits which is administered by the Employer or its designee as an
employee welfare benefit plan as defined by Section 3(l) of the Employ" Retirement Income Security Act of 1974 ("ERISA");
WHEREAS, Employer has retained Business Associate to provide certain claims administrative services with respect to the Plan which am
described and set forth in a separate Master Services Agreement among those parties ("MSA Agreement"), m amended from time to time;
WHEREAS, Employer is authorized to enter into this agreement on behalf of Plan;
WHEREAS, the parties to this Agreement denim to establish the terms under which Business Associate may use or disclose Protected Health
Information (as defined herein) such that the Plan may comply with applicable requirements of the Health Insurance Portability and
Accountability Act of 1996 and its implementing regulations (45 C.F.R. Parts 160-164) ("HIPAA Privacy Regulation' and/or "HIPAA Security
Regulation') and the requirements of the Health Information Technology for Economic and Clinical Health Act, as incorporated in the American
Recovery and Reinvestment Act of 2009 (the "HITECH Act');')), that are applicable to business associates, along with arty guidance and/or
regulations issued by DHHS.
WHEREAS, Plan and Business Associate agree to incorporate into this Agreement any regulations issued with respect to the HITECH Act that
relate to the obligations of business associates. Business Associate recognizes and agrees that it is obligated by law to meet the applicable
provisions of the HITECH Act.
NOW, THEREFORE, in consideration of these premises and the mutual promises and agreements hereinafter set forth, the Plan, Employer and
Business Associate hereby agree as follows:
PART 1—BUSINESS ASSOCIATE'S
PRIVACY OF PROTECTED HEALTH INFORMATION
A. Confidentiality of Protected Health Information
Except as permitted or required by (his Agreement, Business Associate will not use or disclose Protected Health Information without
the authorization of the Individual who is the subject of such information or as required by law.
B. Proldbition on Non -Permitted Use or Disclosure
Business Associate will neither use nor disclose Individuals' Protected Health Information except (1) as permitted or required by this
Agreement, or any other agreement between the parties, (2) as permitted in writing by the Plan or its Plan administrator, (3) as
authorized by Individuals, or (4) as required by law.
C. Permitted Uses and Disclosures
Business Associate is permitted to use or disclose individuals' Protected Health Information m follows:
1. Function and Activities on Plane Behalf
Business Associate will be permitted to me and disclose Individuals' Protected Health Information (a) for the management,
operation and administration of the Plan, (b) for the services set forth in the MSA Agreement, which include (but are not
limited to) Treatment, Payment activities, and/or Health Care Operation as these terms are defined in this Agreement and
45 Code of Federal Regulation ¢ 164.501, and (c) as otherwise required to perform its obligation under this Agreement
and the MSA Agreerent, or any other agreement between the parties provided that such we or disclosure would not
violate the HIPAA Privacy or Security Regulations if done by the Plan and the HITECH Act,
2. Business Associate's Own Management and Administration
a. Protected Health Information Use
Business Associate may use Individuals' Protected Health Information as necessary for Business Associate's proper
management mid administration or to carry out Business Associate's legal responsibilities.
b. Protected Health Information Disclosure
Business Associate may disclose Individuals' Protected Health Information as necessary for Business Associate's proper
management and administration or to tarty out Bninem Associate's legal responsibilities only (i) if the disclosure is
required by law, or (ii) if before the disclosure, Business Associate obtain from the entity to which the disclosure is to be
made reasonable assurence, evidenced by written contract, that the entity will (x) hold Individuals' Protected Health
Information in confidence, (y) use or further disclose Individuals' Protected Health Information only for the purposes for
which Business Associate disclosed it to the entity or as required by law; and (z) notify Business Associate of any instance
of which the entity becomes aware in which the confidentiality of any Individuals' Protected Health Infomation was
breached.
3. Miscellaneous Functions and Activities
a. Protected Health Information Use
Business Associate may use Individuals' Protected Health Inforoation an necessary for Business Associate to perform
Data Aggregation services, and to create Deidentified Infomtation, Summary Health Infmmation and/or Limited Data Sets.
b. Protected Heath Information Disclosure
Business Associate may disclose, in confbmance with the HIPAA Privacy Regulation, Individuals' Protected Health
Information to make Incidental Disclosures and to make disclosures of Deidentified Infortmtion, Limited Data Set
Information, and Summary Health Information.
4. Minimum Necesrary and Limited Data Sec
Business Associate's use, disclosure or request of Protected Health Infamtation shall utilize a Limited Data Setif
practicable. Otherwise, Business Associate will make reasonable efforts to use, disclose, or request only the minimum
necessary amount of Individuals' Protected Health Information to accomplish the intended purpose.
D. Disclosure no Plan and Emalover (and their Subcontractors)
Other than disclosures permitted by Section LC above, Business Associate will not disclose Individuals' Protected Health Information
to the Plan, its Plan administrator or Employer, or any business associate or subcontractor of such parties except as set forth in Section
VIIL
E. Disclosure to Business Associate's Subcontractors and Aaent
Business Associate will require its subcontractors and agents to provide reasonable assurance, evidenced by written contract, that such
other entity will comply with the same privacy and security obligations with respect to Individuals' Protected Health Infomnation as
applies to Bustlers Associate.
F. Remortine Non -Permitted Use or Disclosure. Breaches and Security Incidents
1. Non -permitted Use or Disclosure. Business Associate will promptly report to the Plan any use or disclosure of
Individuals' Protected Health Information not permitted by this Agreement or in writing by the Plan or its Plan
administrator, of which Business Associate becomes aware,
2. Security Incidents. In addition to reporting to Plan any use or disclosure of Protected Health Information not
permitted by the Agreement, Business Associate will also report any Breach or security incidents of which Business
Associate becomes aware. A security incident is an attempted or successful unauthorized access, use, disclosure,
modification or destruction of infomation or interference with system operations in an information system, and
involves only electronic Protected Health Information that is created, received maintained or transmitted by or on
behalf of Business Associate, that is in electronic form. The parties acknowledge and agree that this section
constitutes notice by Business Associate to Company of the ongoing existence and oceurence of attempted but
Unsuccessful Security Incidents (as defined below) for which no additional notice to Company shall be required.
"Unsuccessful Security Incidents" shall include, but not be limited to, pings and other broadcast attacks on Business
Associate's firewall, port scans, unsuccessful log -on attempts, denials of service and any combination of the above,
so long as no such incident results in unauthorized access, use or disclosure of PHI or NPFI.
3. Breach. Business Associate will promptly report to Plan any Breach of Unsecured PHI. Business Associate will
cooperate with Plan in investigating the Breach and in meeting the Plan's obligations under the HITECH Act and
other applicable Security Breach notification laws. In addition to providing notice to Plan of a Breach, Business
Associate will provide any required notice to individuals and applicable regulmors on behalf of Plan, unless Plan is
otherwise notified by Business Associate
G. Terminstlon for Breach of Privacy Oblleadona
Without limiting the lights of the parties set forth in the MSA agreement, each patty will have the right to terminate this
Agreement and the MSA Agreement if the other has engaged in a pattern of activity or practice that constitutes a material
breach or violation of their obligations regarding Protmted Health Information under this Agreement.
Prior to terminating this Agreement as set forth above, the terminating party shall provide the other with an opportunity to
cure the material breach. If these efforts to cure the material breach are unsuccessful, as determined by the terminating
party in its reasonable discretion, parties shall terminate the MSA Agreement and this Agreement, as soon as
administratively feasible. If for any reason a party has determined the other has breached the term of this Agreement and
such breach has not been cured, but the non -breaching party determines that termination of the Agreement is not feasible,
the party may report such breach to the U.S. Department of Health and Human Services.
H. Disposition of Protected Health Information
1. Return or Destruction Uuon MSA Agreement End
The parties agree that upon cancellation, mmimation, expiration or other conclusion of the MSA Agreement, destruction or
return of all Protected Health Information, in whatever form or medium (including in arty eleelronic medium under
Business Associate's custody or control) is not feasible given the regulatory requirements to maintain and produce such
information for extended periods of time after such termination. In addition, Business Associate is required to maintain
such records to support its contractual obligations with its vendors and network providers. Business Associate shall extend
the protections of this Agreement to such Protected Health Information and limit further uses and disclosures of such
Protected Heahh Infomration to those consistent with applicable law for so long as Business Associate, or its
subcontractors or agents, maintains such Protected Health Information. Business Associate may destroy such records in
accordance with applicable lawand its record retention policy that it applies to similar records.
2. Execution When Business Associate Becomes Plan's Health Insurance Is re
If upon cancellation, termination, expiration or other conclusion of the MSA Agreement, Business Associate (or an affiliate
of Business Associate) becomes the Plan's health insurance underwriter, that Business Associate shall transfer any
Protected Health Information that Business Associate created or received for or from Plan to that part of Business
Associate (or affiliate of Business Associate) responsible for health insurance functions.
3. Survival ofTerndnatlon
The provisions of this Section I.H. shall survive cancellation, termination, expiration, or other conclusion of this
Agreement and the MSA Agreement.
IL ACCESS. AMENDMENT AND DISCLOSURE ACCOUNTING
A. Access
Business Associate will respond to an Individual's request for access to his or her Protected Health Information
as part of Business Associate's normal customer service function, if the request is communicated to Business
Associate directly by the Individual. Despite the fact that the request is not made to the Plan, Business
Associate will respond to the request with respect to the Protected Health Information Business Associate and
its subcontractors maintain in a manner and time flume consistent with requirements specified in the HIPAA
Privacy Regulation.
2. In addition, Business Associate will assist the Plan in responding to requests by Individuals that are made to the
Plan to invoke a right of access under the HIPAA Privacy Regulation by performing the following functions:
B. Amendment
Upon receipt of written notice (includes foxed and emailed notice) from the Plan, Business Associate will make
available for inspection and obtaining copies by the Plan, or at the Plan's direction by the Individual (or the
Individual's personal reprvsemative), any Protected Health Information about the Individual created or received
for or from the Plan in Business Associate's custody or control, so that the Plan may meet its access obligations
under 45 Code of Federal Regulations § 164.524, and, where applicable, the HITECH Act. Business Associate
will make such information available in an electronic format where required by the HITECH Act..
Business Associate will respond to an Individual's request to amend his or her Protected Health Information as
part of Business Associate's normal customer service functions, if the request is communicated to Business
Associate directly by the Individual. Despite the fact that the request is not made to the Plan, Business
Associate will respond to the request with respect to the Protected Health Information Business Associate and
its subcontractors maintain in a manner and time home consistent with requirements specified in the HIPAA
Privacy Regulation.
2. In addition, Business Associate will assist the Plan in responding to requests by Individuals that are trade to the
Plan to invoke a right to amend under the HIPAA Privacy Regulation by perfotming the following Junctions:
Upon receipt of written notice (includes faxed and candied notice) from the Plan, Business Associate will
amend any portion of the Protected Health Infomution created or received for or from the Plan in Business
Associate's custody or control, so that the Plan may meet its amendment obligations under 45 Code of Fedora[
Regulations ¢ 164.526.
C. Disclosure Accounting
Business Associate will respond to an Individual's request for an accounting of disclosures of his or her
Protected Health Information as part of Business Associate's normal customer service function, if the request is
communicated to the Business Associate directly by the Individual. Despite the fact that the request is not made
to the Plan, Business Associate will respond to the request with respect to the Protected Health Information
Business Associate and its subcontractors maintain in a manner and time frame consistent with requirements
specified in the HIPAA Privacy Regulation.
2. In addition, Business Associate will assist the Plan in responding to requests by Individuals that am made to the
Plan to invoke a right to an accounting of disclosures under the HIPAA Privacy Regulation by performing the
following functions so that the Plan may meet its disclosure accounting obligation under 45 Code of Federal
Regulations § 164.528:
a. DisclosureTracking
Business Associate will record each disclosure that Business Associate makes of Individuals' Protested Health
Information, which is not excepted from disclosure accounting under Section II.C.2.b.
The information about each disclosure that Business Associate must record ("Disclosure Inf stmatiod) is (a) the
disclosure date, (b) the name and (if known) address of the person or entity to whom Business Associate made
the disclosure, (c) a brief description of the Protected Health Information disclosed, and (d) a brief statement of
the putpose of the disclosure or a copy of any written request for disclosure under 45 Code of Federal
Regulations § 164,502(ax2xii) or § 164.512. Disclosure Information also includes any information required to
be provided by the HfrECH Act
For repetitive disclosures of Individuals' Protected Health Information that Business Associate makes for a
single purpose to the same person or entity (including to the Plan or Employer), Business Associate may record
(a) the Disclosure Information for the first of these repetitive disclosures, (b) the frequency, periodicity or
number of these repetitive disclosures, and (e) the date of the last of these repetitive disclosures.
b. Exceptions from Disclosure Trackina
Business Associate will not be required to record Disclosure Information or otherwise account for disclosures of
Individuals' Protected Health Information (a) for Treatment, Payment or Health Care Operations, (except where
required by the HITECH Act, as of the effective dates of such requirements) (b) to the Individual who is the
subject of the Protected Health Information, to that Individual's personal representative, or to another person or
entity authorized by the individual (c) to persons involved in that Individual's health cam or payment for health
cam as provided by 45 Code of Federal Regulations § 164.510, (d) for notification for disaster relief purposes as
provided by 45 Code of Federal Regulations § 164.510, (e) for national security or intelligence purposes, (f) to
law enforcement officials or correctional institutions regarding inmates, (g) that am incident to a use or
disclosure that is permitted by this Agreement or the MSA Agreement, (h) as part of a limited data set in
accordance with 45 Code of Federal Regulations § 164.514(e), or (i) that occurred prior to the Plan's
compliance date.
C. Dsclos im Trockine Time Pvlods
Unless otherwise provided by the HITECH Act and/or any accompanying regulations, Business Associate will
have available for the Plan the Disclosure Information requited by Section II.C.2.a above for the six (6) years
immediately preceding the date of the Plan's request for the Disclosure Information.
d, Provision of Disclosure Accounting
Upon receipt of written notice (includes fixed and availed notice) from the Plan, Business Associate will make
available to the Plan, or at die Plan's direction to the Individual (or the Individual's personal representative), the
Disclosure Information regarding the Individual, so the Plan may meat its disclosure accounting obligations
under 45 Code of Federal Regulations § 164.528 and the HITECH Act.
D. Confidential Communications
Business Associate will respond to an Individual's request for a confidential communication es par of Business
Associate's normal customer service function, if the request is communicated to Business Associate directly by
the Individual Despite the fact that the request is not made to the Plan, Business Associate will respond to the
request with respect to the Protected Health Information Business Associate and its subcontractors maintain in a
manner and time forme consistent with requirements specified in the HIPAA Privacy Regulation. If an
Individual's request, made to Business Associate, extends beyond information held by Business Associate or
Business Associate's subconna nors, Business Associate will inform the Individual to direct the request to the
Plan, so that Plan may coordinate the request. Business Associate assumes no obligation to coordinate any
request for a confidential communication of Protected Health Information maintained by other business
associates of Plan
In addition, Business Associate will assist the Plan in responding to requests by Individuals that am made to the
Plan to invoke a right of confidential communication under the HIPAA Privacy Regulation by performing the
following functions:
Upon receipt of written notice (includes faxed and entailed notice) from the Plan, Business Associate will begin
to send all communications of Protected Health Information directed to the Individual to the identified alternate
address an that the Plan may meet its access obligations under 45 Code of Federal Regulations § 164.524.
E. Restriction
1. Business Associate will respond to an Individual's request for a restriction as part of Business Associate's
normal customer service function, if the request is communicated to Business Associate directly by the
Individual. Despite the fact that the request is not made to the Plan, Business Associate will respond to the
request with respect to the Protected Health Information Business Associate and its subcontractors maintain in a
manner and time frame consistent with requirements specified in the HIPAA Privacy Regulation.
2. In addition, Business Associate will promptly, upon receipt of notice fmm Plan, restrict the use or disclosure of
Individuals' Protected Health Information, provided the Business Associate has agreed to such a restriction.
Plan and Employer understand that Business Associate administers a variety of different complex health benefit
arrangements, both insured and self -insured, and that Business Associate bs limited capacity to agree to special
privacy restrictions requested by Individuals. Accordingly, Plan and Employer agree that it will not commit
Business Associate to any restriction on the use Or disclosure of individuals' Protected Health Information for
Treatment, Payment or Health Care Operations without Business Associate's prior written approval.
IIL SAFEGUARD OF PROTECTED HEALTH INFORMATION
Business Associate wilt develop and maintain reasonable and appropriate administrative, technical andphysical safeguards, as
required by Social Security Act § 1173(d) and 45 Code of Federal Regulations § 164.530(c) and as required by the HITECH Act, to
ensure and to protect against reasonably anticipated threats or hazards to the security or integrity of health information, to protect
against reasonably anticipated unauthorized use or disclosure of health information, and to reasonably safeguard Protected Health
Information from any intentional or unintentional use or disclosure in violation of this Agme met.
Business Associate will also develop and use appropriate administrative, physical and technical safeguards to preserve the Availability
of electronic Protected Health Information, in addition to preserving the integrity and confidentiality of such Protected Health
Information. The "appropriate safeguards" Business Associate uses in furtheranceof 45 Code of Federal Regulations § 164.530(c),
will also meet the requirements contemplated by 45 Code of Federal Regulations Parts 160,162 and 164, as amended from time to
time.
IV. COMPLIANCE WITH STANDARD TRANSACTIONS
Business Associate wilt comply with each applicable requirement for Standard Transactions established in 45 Code of Federal
Regulations Part 162 when conducting all or any part of a Standard Transaction electronically for, on behalf of, or with the Plan.
V. INSPECTION OF BOOKS AND RECORDS
Business Associate will make its internal practices, books, and records relating to its use and disclosure of Protected Health
Information created or received for or from the Plan available to the U.S. Department of Health and Human Services to determine
Plan's compliance with 45 Code of Federal Regulations Parts 160-64 or this Agreement.
VI. MITIGATION FOR NON PERMITTED USE OR DISCLOSURE
Business Associate agrees to mitigate, to the extent practicable, any harmful effect that is known to Business Associate of a use or
disclosure of Protected Health Information by Business Associate in violation of the requirements of this Agreement.
-PART 2 — PLAN'S RESPONSIBILITIES
VIL PLAN'PLAN'S NOTICE-0F PRIVACY PRACTICES
A. Preparation of Pi n's Notice of Privacy Practices, Plan shall be responsible for the preparation of its Notice of Privacy
Practices ("NPP"). To facilitate this preparation, upon Pan's or Employer's request, Business Associate will provide Plan with its
NPP that Plan may won the basis for its own NPP. Plan will be solely responsible for the review and approval of the content of its
NPP, including whether its content accurately reflects Plan's privacy policies and practices, as well as its compliance with the
requirements of 45 C.F.R. § 164.520. Unless advance written approval is obtained fiom Business Associate, the Plan shall not create
any NPP that imposes obligations on Business Associate that am in addition to or that are inconsistent with the NPP prepared by
Business Associate of with the obligations assumed by Business Associate hereunder.
B. Distribution of Nedec of Prlvacv Praetim Plan shall bear full responsibility for distributing its own NPP as requited by the
Privacy Regulation,
C. China" to Protected Heallh Information Plats shall notify Business Associate of any changes) in, or revocation of,
permission by an Individual to Use or Disclose Protected Health Information, to the extent that such ebange(s) may affect Business
Associate's Use or Disclosure of such Protected Health Information.
PART 3—DISCLOSURE OF PROTECTED HEALTH INFORMATION TO THE PLAN, EMPLOYER AND OTHER BUSINESS
ASSOCIATES
Vlll. DISCLOSURE OF PROTECTED HEALTH INE RMATION
The following provisions apply to disclosures of Protected Health information to the Plan, Employer and other business associates of the Plan.
A. Disclosure to Plan
Unless otherwise provided by this Section VIII, all communications of Protected Health Information by Business Associate shall be
directed to the Plan.
B. Dlgetosure to Employer
Business Associate may provide Summary Health Information regarding the Individuals in the Plan to Employer upon Employer's
written request for the purpose either (a) to obtain premium bids for providing health insurance coverage for the Plan, or (b) to modify,
amend or terminate the Plan.
Business Associate may provide information to Employer on whether an individual is participating in the Plan or is enrolled in or has
dismantled from any insurance coverage offered by the Plan.
C. Disclosure to Other Business Associates and Subcontractors
Business Associate may disclose Individuals' Protected Health Information to other entities or business associates of the Plan if the
Plan authorizes Business Associate in writing to disclose Individuals' Protected Health Information to such entity or business
associate. The Plan shall be solely responsible for ensuring that any contractual relationships with these entities or business associates
and subcontractors comply with the requirements of 45 Code of Federal Regulations § 164.504(e) and § 164.504(t).
PART 4—MISCELLANEOUS
IX. AOREEMENTTERM
This Agreement will continue in full force and effect for as long as the MSA Agreement remains in full tome and effect. This Agreement will
terminate upon the cancellation, termination, expiration or other conclusion of the MSA Agreement.
X. AUTOMATIC AMENDMENT TO CONFORM TO APPLICABLE LAW
Upon the effective date of any final regulation or amendment to final regulations with respect to Protected Health Information, Standard
Transactions, the security of health information or other aspects of the Health Insurance Portability and Accountability Act of 1996 applicable to
this Agreement or to the MSA Agreement, this Agreement will automatically amend such that the obligations imposed on the Plan, Employer,
and Business Associate remain in compliance with such regulations, unless Business Associate elects to terminate the MSA Agreement by
providing Employer notice of termination in accordance with the MSA Agreement at least thirty (30) days before the effective date of such final
regulation or amendment to final regulations.
M. CONFLICTS
The provisions of this Agreemart will override and control any conflicting provision of the MSA Agreement. All other provisions of the MSA
Agreement remain unchanged by this Agreement and in full force and effect.
XII. NO THIRD PARTY BENEFICIARIF.3
The parties agree that them are an intended third party beneficiaries under this Agreement. This provision shall survive cancellation, termination,
expiration, or other conclusion of this Agreement and the MSA Agreement.
XIH. INTERPRETATION
Any ambiguity in this Agreement or the MSA Agreement or in operation of the Plan shall be resolved to maintain compliance with the
Regulations enacted pursuant to HIPAA Administrative Simplification.
XIV. DEFINITIONS
Unless otherwise defined in this Agreement, the capitalized terms set forth herein have the meanings ascribed to them under the HIPAA Privacy
Regulation and/or HIPAA Security Regulation or the HITECH Act. A reference in this Agreement to the Privacy Regulation, Security
Regulation or HIPAA shall mean the section as in effector as amended.
XV. REFERENCES
References herein to statutes and regulations shall be deemed to be references to those statutes and regulations as amended or modified.
MUTUAL OF OMAHA INSURANCE COMPANY
AM
UNITED OF OMARA LIFE INSURANCE COMPANY
Mutual of Omaha Plaza
IQJ
Omaha NE 68175
Mills — srOf-YI e
Home Office Use Only
Policy Number(s):
Croup Insurance Application
Applicant (Fall Legal Name) City of Vernon
Address 430E South Santa Fe Avenue0
city Vernon 0
State CA Zip 900580
Requested Effective Date: 01-.01-2014 0
, subject to our acceptance of this application and
payment of premium on or before such date.
�avaneefer beans inalled for,•
Life
NWAD&D
Short Tenn Disability
Long Term Disability
Dental
Critical Illness
GROUP VOLUNTARY
x x
Active at work reaulremeM: Ao employee must meet an Active at Work requirement to become insured. Will all
proposed insureds meet the Active at W uric requinmenl? ❑ Yes 0 No If"No," please provide the name of the
individual, date of birth, date of disability or confinement and nature of disability or confinement on a separate page.
Cortain states have enacted legislation that requiem insurers to provide Specific coverage for people residing in their
states. Do you have employees residing in or working in otter states? 0 Yes ONo
If °Yes," which orates,
Arizona
Financial Rlsk (If "Yes," to any part, please explain bafow)
1. Has the applicant ever filed for bankruptcy? 0 Yes No
2. Does the applicant anticipate causing or materially reducing active business operations? 0 Yes KI No
Fatplanaton: ■
Application is made on the basis of the proposal, any avaikablo experience time and the information contained in this
application.
The applicant signing below agrees to accept the terms and provisions of the Master Policy for the coverages applied for
above, Insurance will become effective on the requested effective date shown above, unless we send written notice of a
different 6ffectivedette. if this application is not approved by an officer at the Home Office of the underwriting company,
no insurance is in enact at any time and any advance payment received will be returned.
This application it submitted with the fbllowingadvence Payment $ SIS . 04
California: Poryour protacton California law requires the roeowmg to appear on tars rorm. Any Parson woo
knowingly presents false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to
fines and ooafinemanta in two prison.
For Applicant Name of Broker, agent and/or Insurance agency
6 so Na th�o�riejiPNr�•�rvG�('bi�(N� �t
(Title)
itj�
(ate)
106340A.EZ 0110
Group Benefits Confirmation Form
Thank you for adding coverage to your existing account.
Sections to be completed by the Customer
Form Effective Date Completion Status
1. Customer Information ........
2. Billing Information .............................
3. Dental Customer Information ....... 01/01/2014
4. Authorizations .................................
5. Master Application .............................
Sections to be completed by the Broker
Form Completion Status
1. Producer(Broker)Information ...................
2. Master Application .............................
Implementation Requirements
List of Items to Complete
MetLife Group Benefits Confirmation Form
Sold Cost & Benefit Summary - The Sold Cost & Benefit Summary (C&B) is a copy of the quote showing the plan
designs and the rates sold.
Complete eCensus list of participating employees (and dependents if applicable) that contains: full name,
address, Social Security Number, date of birth, gender, date of hire, job title, salary/pay mode, worksite zip code,
and class.
When Benefits End
Date Eligible; If selected, coverage will end on actual date of termination for all lines of coverage.
First of the Month, If selected, coverage will terminate at the end of the month following termination date.
RFP ID: i5V3051
Group Benefits Confirmation Form
--e
Customer Information
Customer Number * 5723438
........................
Full Legal Group Name * City of Vernon
Employer Fed Tax ID # *95-6000808 Effective Date * 01/01/2014
Street Address * 4305 S SANTA FE AVE
City *VERNON State *CA Zip * 90058
n Mailing Address is the same as Headquarters Address
On o act 6A,behalfof
First Name * Teresa Last Name * McAllister MetLink Access? * [✓!Yes [ !No
Phone Number* (323) 583-8811 Ext: 239 Fax Number _ Email Address *tmcallister@ci.vernon.ca.I
171 Same as Executive Contact
First Name* Karina Last Name* Rueda MetLink Access? * ✓j Yes I Ao
Phone Number * (323) 583-8811 Ext: 325 Fax Number _ _ Email Address *krueda@ci.vernon.ca.us
RFP ID: b5Y3951
Group Benefits Confirmation Form c -o
Billing Information
[✓[ Same as Headquarters Address [ Same as Mailing Address [� TPA Billed
Street Address * 4305 S SANTA FE AVE
City * VERNON State * CA Zip * 90058
Employer Fed Tax ID # * 95-6000808 _ # of participants at this location *250
✓_I List Bill * i
I_ Self -Administered Premium
*All Voluntary Products Must Be List Billed.
Departmental Billing? Yes [✓[ No Option to produce one bill with employees subtotaled by Location/Division
MP
Click Add Location button if you have employees who are actively at work and are eligible for
coverage at additional location(s) (Please do not re-enter HQ address.)
For additional information please visit our web site at: http://www.metlifeiseasier.com/smailmarketnews/tutorial/start.htm
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/MyBenefits.
Do you wish to provide MetLink access to additional users? * ✓ I Yes I. I No
Do you wish for your broker to have MetLink access for your group? 1 Yes [✓: No
As a MetLink user would you like to stop paper bill generations? * 1 ;Yes [✓; No I Go Green
MetLink allows online access to your billing statement and provides you capabilities to make updates as needed.
Will you be sending an ongoing electronic enrollment/eligibility file?* i Yes ✓i No
Note: This is a separate ongoing file that does not refer to your initial electronic census.
RFP 10- 1-SY3951
Group Benefits Confirmation Form
Dental Group Benefits Confirmation
Group Name * City of Vernon
Are Dependents Being Covered? 1✓I Yes I _ No
Dependent Age* 26 Full -Time Student Age * 26
*specific state restrictions may apply to dependent age limits
Are you ggrinently covering any Mentally Handicapped or Physically Handicapped Dependents? * I J Yes ✓I No
Do you want Domestic Partnerships to be covered? * i✓, Yes _. No Do you have a Section 125 Plan? * 1,/I Yes I No
Note: Some states and / or coverages may not permit domestic partnerships.
Does this product have multiple classes? * ( ,'Yes ✓'i No
Class Description All Active Full Time Employees working * 30 hours per week.
Do you want to cover retirees?* ✓j yes I!No
Prior approval from MetLife (Underwriting) is required if retirees are to be considered eligible.
✓I Open Class - present and future retirees *
Eligibility Definition to be included in your certificate (ie, years of service, age, etc.) * Please see attachement
Closed Class -those retired prior to the effective date
Employee Waiting Period Enter Present Employee Waiting Period* None Days
Enter Future Employee Waiting Period * None Days
Date Eligible; If selected, coverage will start on date employee satisfied his/her applicable
waiting period
First of the Month; If selected coverage will start on the 1st of month following date employee satisfies his/her
waiting period *
ERISA - a federal law that governs most employer established welfare benefits plans. It is the employer's responsibility to provide
certain information to plan participants and the Department of Labor and comply with the other requirements. You may also obtain
additional information about ERISA at www.dol.00
Include ERISA Plan Information in your certificate booklets? * 1 Yes ✓I No
RFP ID: i5V3e51
Benefits Confirmation
Authorizations
Instructions: The individual authorized by the company to sign the Application For Group Insurance must complete the following
Certification section of this form to confirm actions that the company has requested or undertaken with respect to the
implementation of MetLife insurance and/or service program(s). Please read carefully and complete by checking all boxes that
apply.
Certification: I certify that I am the individual authorized by the company named on the attached Application For Group Insurance
to sign the application on behalf of the company. By checking any box below, and by signing and submitting the Application For
Group Insurance, I certify on behalf of the company the accuracy of the statement immediately following each checked box.
By checking this box and signing the Application for Group Insurance, I certify that the Gramm -Leach -Bliley (Consumer) Privacy
I✓j Notice has been distributed to all affected employees. You can view and/or print a copy of the Gramm -Leach -Bliley Privacy
Notice through the link provided: *
https://_Qforms.metlife.com/wem8/OIDAction.do?Q]D=4685
Iyl By checking this box and signing the Application for Group Insurance, I certify that I have received a copy of the Intermediary
Compensation Notice. *
https //eforms.metlife.com/wcm8/OIDAction.do9OlD=26685
I am an authorized representative of the MetLife customer named on this document. I have read and understand the HIPAA
Information for New MetLife Group Dental and/or Vision Insurance Customers. By my signature at end of this form, I, confirm that
the customer: (Select ONE of the three options 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)
Has reviewed and adopted the Sample Summary Plan Description HIPAA Privacy Language for use in its summary plan
description. The customer has submitted a completed and signed copy of the HIPAA Request Form.
Click on the following link to access the Sample Summary Plan Description HIPAA Privacy Language:
httos://eforms M tlife_com&aMa/.QIDActk n.do?OID=30442
By checking this box and signing the Application for Group Insurance, I certify that I have received a copy of the HIPAA
U Information for New MetLife Group Dental and/or Vision Insurance Customers.
Go Green '_ <
The company is requesting that MetLife deliver the group insurance policy and certificates to the company via e-mail as Adobe pdf
documents and confirms that it is able to save them as electronic records and print them for distribution to individuals who become
covered under the group insurance policy. (Please note: If the company is unable or unwilling to accept each of these documents
electronically check "Do Not Send Electronic Policy and Certificates" and a paper copy of each will be sent to the company.)
I authorize Metlife to send electronic Policy & Certificates to 1 would like a Paper Policy & Certificate sent to me the
me the Employer * ( Employer
RFP ID: 15V3051
Group Benefits Confirmation Form
--o
HIPAA Request
If you wish to include in your booklet certificate the HIPAA privacy language shown on the specimen "Sample Dental and/or Vision
Booklet Certificate/SPD Language" provided to you by MetLife, please answer the following questions, sign, and return this form to
your MetLife Sales Office.
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.
PLEASE DO NOT PROVIDE THEIR NAMES; ONLY TITLE OR OTHER IDENTIFIER.
Title Director of Human Resource Title Administrative Assistant Title Department Secretary
Title
Title
Title
B. Should the term "Privacy Officer" be included in Section III. (c) "Sharing of PHI with the Plan Sponsor" of the Dental and/or
Vision Plan Document?
U Yes 11 No
C. Should Section IV. "Participant's Rights" be included in the Dental and/or Vision Plan Document? (This is an optional section.)
Yes 11 No
D. Should Section V. "Privacy Complaints/Issues" be included in the Dental and/or Vision Plan Document? (This is an optional
section.) *
1_✓I Yes [.] No
As a duly authorized representative of the Customer named below and its group dental and/or vision 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 * City of Vernon
Authorized Representative * Teresa_ McAllister Date *10/30/2013 -
RFP ID: 1-5V3651
Group Benefits Confirmation Form
Producer (Broker) Information
Group Name * City of Vernon _
Commission Paid to: IVI Producer* 1_.i Corporation
Are commissions being split between more than one producer?
If yes, please complete a form for each. * L] Yes ✓/1 No
Would you prefer to receive ongoing commissions payments electronically? * [] Yes No
Is there a Third Party Administrator (TPA) or General Agent (GA) associated with the sale? * J Yes [] No
Please complete Non -Standard Commission Agreement Form below.
For Producer Appointment Inquiry Form please visit our web site at: https://eforms.metlife.com/wcmB/0IDAction.do?OID=2580
..
First Name * PATRICIA Middle Initial Last Name *MOORE
SSN *330-78-5439 Producer's Email Address * pamoore@alliant.com
Street Address * 333 S HOPE ST STE 3750
City* LOS-ANGELES State *CA Zip * 90071-3047
Contact at Producer's Office * Kim Hauk Contact's Email Address * khauk@alliant.com
Phone Number* (213)270-0980 -- Ext. ,.. __.._ Fax Number
Ll NEF Agent I_ I Metlife Career Agent [_1 Metlife Resource
RFP ID: i5V3R51
Group Benefits Confirmation Form
--o
MetLife
U.S. Business - Sales & Broker Compensation Services
Non -Standard Commission Agreement
This Agreement between Metropolitan Life Insurance Company ("MetLife") and the undersigned producer ("Producer") is effective for first and
subsequent year commissions, if applicable, for the customer.
1. Commissions. Producer will receive commissions from MetLife for each coverage sold in the month after premium is received by MetLife.
Monthly payments will be determined by applying the attached schedule to the actual premium received per line of sold coverage within the policy
year, and subtracting the commissions already paid during the policy year. Commissions are calculated based on premium received by line of
coverage and will be paid so long as (a) Producer is licensed by the applicable State Insurance Department and appointed by MetLife to sell the
insurance provided by the policy; (b) Producer services the business; (c) MetLife recognizes Producer as the agent/broker of record; (d) any
commission advances or overpayments have been properly recovered by MetLife; (a) the policy remains in force; and (f) this Agreement is in effect.
2. Risk Acceptance, It is understood and agreed that MetLife retains the exclusive right to (a) bind or commit MetLife on any risk in any matters;
(b) decline any application for insurance submitted by the Producer; (c) discontinue any form of policy in any or all jurisdictions in which MetLife
does business; and (d) resume the use of any policy at any time.
3 Overpayments It is agreed that any overpayment of commissions which may occurdue to clerical error; cancellation of coverage; refund of
premium; payment of any advance if applicable; change of agent/broker of record by the policyholder or MetLife; or any other reason, will be
returned to MetLife by the Producer. It is further agreed that MetLife is authorized to recover any overpayments from the current or future
commission owed the Producer by MetLife or its affiliates. Producer agrees to reimburse MetLife for expenses, including costs and attorneys' fees,
associated with the collection of outstanding debts due MetLife from Producer.
4. Independent Contractor. Producer acknowledges and agrees that it is an independent contractor and not an employee of MetLife. (Note: Not
applicable to MetLife Financial Services Representatives.)
6. Notices. If Producer receives notice of the commencement of any legal, regulatory or administrative proceedings involving MetLife or Producer,
or if it receives any communication from any Insurance Department or other administrative agency or any other person identifying a complaint
registered. against MetLife or Producer, Producer shall, following receipt of such notice,immediately notify MetLife of the proceeding or complaint,
and promptly forward any correspondence or necessary files.
6. Customer Information. Producer agrees to treat all information about individuals who enroll, apply for or purchase Mett-ife's products or
services that Producer may have or may obtain in connection with its obligations under this Agreement ("Customer Information") as confidential.
Customer Information may include, but is not limited to, an individual's name, address, social security number, as well as any financial or health
information relating to the individual. Producer may use Customer Information, in accordance with MelLife's privacy policy, only for the purpose of
fulfilling its obligations under this Agreement and Producer may not disclose Customer Information to anyone other than the individual to whom the
information relates, except as required for Producer to fulfill its obligations under this Agreement or as otherwise directed by MetLife, or except as
expressly required by law. Producer must also ensure that Customer Information is maintained, stored and transmitted in a secure manner in
accordance with all applicable laws. To the extent that Producer becomes aware of a failure of security measures or any use or disclosure of
Customer Informationthat is not .permitted by this Agreement, Producer shall immediately report such incident to MetLife at
securitybreach@metlife.com and cooperate with MetLife to fulfill any resulting legal obligations.
7. Protected Health Information. 7.1. In order to comply with the Health Insurance Portability and Accountability Act of 1996 ("HIPAA"), as
amended by the Health Information Technology for Economic and Clinical Health Act ("HITECH Act") and to further protect the confidentiality of any
Protected Health Information "PHI" (as defined below) disclosed to or used by Producer pursuant to this Agreement, MetLife and Producer agree to
the following with respect to any PHI received or created by Producer in providing services pursuant to this Agreement, including PHI received or
created prior to the effective date of this Agreement ("MetLife PHI"): (a) the obligations regarding MetLife PHI contained in this section shall be in
addition to any other obligations contained in this Agreement that apply to MetLife PHI; (b) Producer may not use or disclose MetLife PHI except to
provide services pursuant to this Agreement; (c) Producer shall use appropriate safeguards to prevent use or disclosure of MetLife PHI; (d) MetLife
and Producer represent and warrant that their security procedures are adequate to protect and maintain the confidentiality of MetLife PHI; (a)
Producer shall promptly report to MetLife any use or disclosure of MetLife PHI not permitted by this Agreement of which it becomes aware; (f)
Producer shall ensure that any agents, including any sub -contractors or Producer affiliates, that Producer may use in accordance with this
Agreement and to whom Producer provides MetLife PHI or who uses MetLife PHI has been approved by MetLife in writing and agrees to the same
restrictions and conditions that apply to Producer with respect to MetLife PHI pursuant to this Agreement; (g) within fifteen (15) days of Meti-ife's
request, Producer shall provide to MetLife any MetLife PHI or information relating to MetLife PHI as deemed necessary by MetLife to comply with its
obligations under HIPAA to provide individuals with access to, amendment of, and an accounting of disclosures of their MetLife. PHI, and Producer
agrees to incorporate any amendments of the MetLife PHI as requested by MetLife; (h) Producer agrees to make its internal practices, books, and
Non -Standard Commission Agreement (05/13) Page 1 of 4
RFP ID: 1SY3B51
Group Benefits Confirmation Form
--o
7. Protected Health Information (continued). records relating to its use or disclosure of MetLife PHI available to the Secretary of the United
Slates Department of Health and Human Services at his/her request to determine Meti-ife's compliance; (i) Producer agrees that upon termination
of the Agreement it will, if feasible, return or destroy all MetLife PHI it maintains in any form and retain no copies, and if such return or destruction is
not feasible, Producer agrees to extend the protections of this Agreement to the MetLife PHI beyond the termination of this Agreement and further
agrees that any further use or disclosure of the MetLife PHI will be solely for the purposes that make return or destruction infeasible; (j) Producer
agrees that it will not disclose MetLife PHI, other than enrollment information, to an employer or plan sponsor, unless the employer or plan sponsor
has taken the steps required by HIPAA to permit disclosure to the employer or plan sponsor; (k) Producer may use or disclose MetLife PHI to the
extent that such use or disclosure is required by law and the use or disclosure complies with and is limited to the relevant requirements of such law,
and only to the extent that such use or disclosure complies with any applicable HIPAA requirements relating to uses and disclosures required by
law; and (1) Producer shall (1) implement administrative, physical, and technical safeguards that reasonably and appropriately protect the
confidentiality, integrity, and availability of any electronic MetLife PHI that Producer creates, receives, maintains, or transmits on behalf of MetLife;
(2) ensure that any agent of Producer, including anysubcontractor or Producer affiliate to whom Producer provides electronic MetLife PHI, agrees
to implement reasonable and appropriate safeguards to protect electronic. MetLife PHI; and (3) report to MetLife any security incident related to
electronic MetLife PHI of which Producer becomes aware. 7.2. Producer agrees and acknowledges that it is directly subject to HIPAA, as amended
by the HITECH Act, including. its provisions relating to security and privacy of PHI as well as its enforcement and penalty provisions. Producer
agrees that it shall: (a) comply with all applicable security and privacy provisions of HIPAA as amended by the HITECH Act and as it may be
amended from time to time; (b) not act in any way to interfere with or hinder Meti-ife's ability to comply with HIPAA, as amended by the HITECH Act
and as it may be amended from time to time; and (c) notify MetLife within five (5) business days after discovering a "breach" as that term is defined
in Section 13400 of the HITECH Act at the following e-mail addresssecuritybreach@metlife.com. 7.3. In the event Producer learns of a pattern of
activity or practice of MetLife that constitutes a material breach or violation of its obligations relating to PHI under this Agreement, Producer shall
take reasonable steps to work with MetLife to cure the breach or end the violation. If such steps are unsuccessful, Producer shall terminate this
Agreement, if feasible, or, if termination is not feasible, report the problem to the Secretary of Health and Human Services. 7.4. Protected Health.
Information ("PHI") is defined in HIPAA as individually identifiable information that is transmitted or maintained in any medium and relates to: the
past, present or future physical or mental health or condition of an individual; the provision of health care to an individual; or past, present, or future
payment for the provision of health care to the individual. MetLife and Producer understand that this definition of PHI includes demographic
information about the individual, including names; geographic subdivisions smaller than a state (including but not limited to street addresses and
ZIP codes); all elements of dates (except year) for dates directly related to an individual, including but not limited to birth date; telephone numbers;
fax numbers; electronic mail (E-mail) addresses; Social Security numbers; Medical record numbers; health plan beneficiary numbers; account
numbers; certificate/license numbers; vehicle identifiers and serial numbers, including license plate numbers; device identifiers and serial numbers;
Web Universal Resource Locators (URL's); Internet Protocol (IP) address numbers; biometric identifiers, including finger and voice prints; full face
photographic images and any comparable images; and any other unique identifying number, characteristic, or code. 7.5. Producer's breach of any
of the provisions of Paragraph 7 shall constitute material breach of this Agreement and provide grounds for immediate termination by MetLife,
notwithstanding any other provision of the Agreement
8. Amendments_ MetLife reserves the right to amend this Agreement by providing Producer with thirty (30) days prior written notice of the change
9 Advertising. For the sale or marketing of MetLife. products, Producer shall use only sales material approved in writing. by MetLife.
10 Termination MetLife may terminate this Agreement at any time for any or no reason, Additionally, this Agreement shall terminate immediately
if (a) Producer is no longer appointed by MetLife to sell its products; (b) Producer is not licensed by the applicable state insurance department; (c)
Producer breaches any provision of this Agreement; (d) Producer commits or its agents commit fraud, embezzlement, gross negligence or other
legal misconduct. The rights and obligations established under Sections 3, 5, 6, and 7, hereof, shall survive the termination of this Agreement.
METROPOLITAN LIFE INSURANCE COMPANY
` , W
Dean Witte, VP Sales Compensation Administration
PATRICIA MOORE 10/30/2013
Producer's Signature Date
PATRICIA MOORE
Producer's Printed Name"
330-78-5439
Social Security Number (Tax ID if Corporation)
Non -Standard Commission Agreement (05/13) Page 2 of 4
RFP to i5V3B51
Group Benefits Confirmation Form
--o
MetLife
U.S. Business - Sales & Broker Compensation Services
Non -Standard Commission Agreement
MetLife Non -Standard Commission Schedule for
Coverage sold
{ ] Basic Life/AD&D
_ Core Life/AD&D
[_ ] Dependent Life
[ ] Buy -Up Life/AD&D & Dependent Life AD&D
Enhanced Optional Life/AD&D & Dependent Life AD&D
J Short Term Disability
Core Short Term Disability
L_J Buy Up Short Term Disability
F I State Mandated Disability
Voluntary Short Term Disability
_] Long Term Disability
Core Long Term Disability
Buy Up Long Term Disability
Dental
J Vision
DHMO - Florida
X DHMO - California
[_ ] DHMO - Texas
DHMO - New Jersey
--] Managed Dental Plan - New York
DHMO - Illinois
City of Vernon
Non -Standard Commission
% of annual premium
• of annual premium
% of annual premium
• of annual premium
• of annual premium
% of annual premium
% of annual premium
of annual premium
• of annual premium
• of annual premium
• of annual premium
• of annual premium
% of annual premium
3 % of annual premium "
• of annual premium
% of annual premium
3 % of annual premium .
% of annual premium
% of annual premium
• of annual premium
• of annual premium
Non -Standard Commission Agreement (05/13) Page 3 of 4
RFP ID; 1-5V3D51
Group Benefits Confirmation Form
--o
If you are a MetLife Financial Services Representative, Senior Partner or Unified Brokerage Associate, or New England Financial
Agent or Broker, the commission amounts shown above will be treated as Gross Dealer Concessions ("GDC") and compensation will
IPATRICIA MOORE
Producer's Signature
10/3012013
Date'
PATRICIA MOORE
Producer's Printed Name
330-78-5439
Social Security Number (Tax ID if Corporation)
Customer Number
City of Vernon
Customer Name *
Non -Standard Commission Agreement (05113)
Page 4 of 4
RFP ID: 1-SV3B51
Group Benefits Confirmation Form MetLife
MetLife
Benefits provided by SafeGuard Health Plans, Inc.,
a Metlife company
200 Park Avenue, New York, New York 10166
APPLICATION FOR GROUP DENTAL BENEFITS
The applicant named below is applying for a Group Contract to provide dental benefits for the persons specified below.
APPLICANT DATA
1. Full legal name of Applicant: *City of Vernon
2. Address: * 4305 S SANTA FE AVE
CONTRACT EFFECTIVE DATE
The Group Contract's effective date will be * 01/01/2014
this application.
CONTRACT SITUS
City * VERNON
State * CA Zip * 90058
, subject to MetLife's acceptance of
The Group Contract will be issued for delivery in and governed by the laws of * California
COVERAGE DATA
Dental Benefits
PREPAYMENT FEE DATA
Employees / Members Only
Employees / Members and Dependents
Prepayment Fees will be paid: ® monthly * ❑ quarterly ❑ annually ❑ other:
Attached is an advance payment of: $ * 0.00
//
AGREEMENT
The Applicant signing below agrees to accept the terms and provisions of the Group Contract, 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 or statement of claim containing any materially false information, or conceals for the purpose of misleading,
information concerning any material fact thereto commits a fraudulent act, which is a crime and subjects such person to
criminal and civil penalties.
Signature of Applicant's Legal Representative
Signed at: City of Vernon State CA
Name of Legal Representative Teresa McAllister
Title of Legal Representative Director of Human Resources
Applicant Signature *******
Signature of Licensed MetLife Agent or Resident Agent as required by law
Agent's State License No. * OC36861
Name of Agent: * PATRICIA MOORE
Agent Signature *
(SafeGuard Representative)
Date: 10/3012013
Date: * 10/30/2013
Assistant Vice President Isaac Torres
(Representative's title) (Print Name of Representative)
APP-GPI O-DHMO CA
Group Benefits Confirmation Form Meftife*
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 S SANTA FE AVE City *VERNON State *CA Zip * 90058
POLICY EFFECTIVE DATE
The Group Policy's effective date will be * 01101/2014 subject to MetLife's acceptance of
this application and the Applicant's payment of the Premium due on or before such date.
POLICY SITUS
The Group Policy will be issued for delivery in and governed by the laws of California.
COVERAGE DATA
Basic Life
Basic Life with AD&D
(Note: Basic AD&D is not available for Dependents)
Supplemental Life
Supplemental Life with AD&D
Dental
Short Term Disability
Long Term Disability
Vision
PREMIUM DATA
Premiums will be paid: ® monthly * ❑ quarterly
Attached is an advance payment of: $ * 0.00
AGREEMENT
Employees / Members
Only
El
El
❑ annually ❑ other:
Employees / Members
and Dependents
1-1
El
■
■
El
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 crime and
subjects such person to criminal and civil penalties.
Signature of Applicant's Authorized Representative
Signed at: City of Vernon State CA Date: 10/30/2013
Name of Authorized Representative Teresa McAllister
Title of Authorized Representative Director of Human Resources
Applicant Signature
Signature of Licensed MetLife Agent or Resident Agent as required by law
Agent's State License No. * OC36861
Name of Agent: * PATRICIA MOORE
Agent Signature *
Date: * 10/30/2013
APP-GP99 NWIF
Group Benefits Confirmation Form
--o
Special Instructions
RFP ID: i5YBB51