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HomeMy WebLinkAbout2015-141-E County Manager - UnitedHealthCare of NC - Amendment to Excess Loss Insurance Policy $635,758 DocuSign Envelope ID: 7DB9202D-FDA8-426E-8A84-EAE7538E9310 UnitedHealthcare Insurance Company A Stock Company 185 Asylum Street,Hartford,Connecticut Phone: 1-860-702-5000 ii i AMENDMENT NO. 1 Amendment to be attached to and made a part of Group Policy No. GA-743058, issued by UnitedHealthcare Insurance Company (herein called "Company") to Orange County (herein called "Policyholder"). It is agreed by and between the Company and the Policyholder that 1. The page entitled "Schedule Of Benefits" as contained in the Policy is hereby replaced with the attached page entitled"Schedule Of Benefits". 2. This Amendment will hereby be effective as of January 1,2015. UnitedHealthcare Insurance Company Jeffrey Alter,President Thomas J.McGuire, Secretary rii)OCUSIgned by: ACCEPTED BY: OV�,I�t tf. �AaMw�t V S�t 1? 063 9 4 Title: county Manager Date: 2/23/2015 UHIC AMEND(07/06) i DocuSign Envelope ID: 7DB9202D-FDA8-426E-8A84-EAE7538E9310 UnitedHealthcare Insurance Company A Stock Company 185 Asylum Street,Hartford,Connecticut Phone: 1-860-702-5000 SCHEDULE OF BENEFITS This Schedule of Benefits is only applicable to Excess Loss Insurance provided by the Company during the Policy Period shown below. Policyholder: Orange County Policy Number: GA-743058 Effective Date: January 1,2015 Administrator: United HealthCare Services,Inc. Coverage specified herein is applicable only during the Policy Period from January 1, 2015 through June 30,2015,and is further subject to all terms and conditions of this Policy. t SPECIFIC EXCESS LOSS INSURANCE Benefit Period: Covered Expenses Incurred from January 1, 2014 through June 30, 2015 and Paid from January 1,2015 through June 30,2015. Specific Deductible per Covered Person: $100,000 Specific Percentage Reimbursable: 100% Maximum Specific Benefit per Covered Person:Unlimited Specific Excess Loss Insurance includes: • Medical • Stand Alone Prescription Drug Program Specific Excess Loss Premium: $107.03 per subscriber per month UHIELIP(07/06) 2 SCHED t E DocuSign Envelope ID: 7DB9202D-FDA8-426E-8A84-EAE7538E9310 / 1 ® DATE(MMIDDIYYYY) CERTIFICATE OF LIABILITY INSURANCE 04/24/20,4 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies) must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: Marsh USA Inc. 333 South 7th Street,Suite 1400 (A/C PHONE, Ext: a c No): Minneapolis,MN 55402-2400 E-MAIL Attn:Healthcare.AccountsCSS @marsh.com Fax 212-948-1307 ADDRESS: INSURERS AFFORDING COVERAGE NAIC# 401115-OLD-PL5M-14-16 INSURER A:Old Republic Insurance Company 24147 G INSURED INSURER B: UNITEDHEALTH GROUP 9900 BREN ROAD EAST MN008-W345 INSURER c: MINNETONKA,MN 55343 INSURER D: INSURER E: INSURER F. i COVERAGES CERTIFICATE NUMBER: CHI-004227576-12 REVISION NUMBER:10 THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.POLICY EXP INSR TYPE OF INSURANCE INSR SUER POLICY NUMBER MM%POLICY DNYYY LTR MMIDDNYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO RENTED COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence $ CLAIMS-MADE E]OCCUR MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ GENT AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ POLICY JEO LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS Per accident $ UMBRELLA LIAR HOCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ 19 WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY YIN L S E ANY PROPRIETOR/PARTNER/EXECUTIVE❑ N/A E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ A Managed Care MWZZ302190 05101/2014 05/01/2016 Each Claim $5,000,000 Professional Liability/E&O RETRO DATE:111R7 Annual Aggregate $5,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) CERTIFICATE HOLDER CANCELLATION UNITEDHEALTH GROUP SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 9900 BREN ROAD EAST MN008-W345 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN MINNETONKA,MN 55343 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE of Marsh USA Inc. Manashi Mukherjee ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD