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HomeMy WebLinkAbout2015-393-E HR - UnitedHealthCare (UHC) for UHC Application for Excess Loss Insurance Policy $1,265,095 DocuSign Envelope ID: EE765B38-37EF-4402-B4E9-8B82F98E2EE8 UnitedHealthcare Insurance Company STOP LOSS POLICY FOR Orange County Policy Number: GA-905040 Effective Date: July 1, 2015 State or other Jurisdiction of Issue: North Carolina DocuSign Envelope ID: EE765B38-37EF-4402-B4E9-8B82F98E2EE8 UNITEDHEALTHCARE INSURANCE COMPANY A Stock Company 185 Asylum Street,Hartford, Connecticut Phone: 1-860-702-5000 UnitedHealthcare Insurance Company ("Company") agrees to reimburse the Policyholder as outlined under the provisions of this Excess Loss Insurance Policy("Policy"). This Policy is legally binding between the Policyholder and UnitedHealthcare Insurance Company. The consideration for this Policy includes, but is not limited to, the Application and the Payment of premiums as provided hereinafter. The Policyholder is entitled to the reimbursement described in this Policy if the Policyholder is eligible for insurance under the provisions of this Policy. Reimbursement is subject to the terms and conditions of this Policy. The first premium is due on the first(1st) day of the Policy Period. Subsequent monthly premiums are due on the first (1st) day of each month thereafter. The premium is not considered Paid until the Company receives the premium payment. All periods of coverage will begin and end 12:01 a.m.local time at the principal office of the Policyholder. This Policy is delivered in and is governed by the laws of the state of issue. IN WITNESS WHEREOF UnitedHealthcare Insurance Company has caused this Policy to be executed by its President and Secretary. IMPORTANT NOTICE - READ YOUR POLICY CAREFULLY This Policy is a legal contract between you and us. We issued it on the basis that the information in your application is correct and complete. Check this information carefully.If it is not correct and complete,write to our Administrative Office and provide the correct and complete information. Jeffrey Alter,President Michael J. McDonnell, Secretary STOP LOSS INSURANCE POLICY IMPORTANT CANCELLATION INFORMATION- Please Read The Provision Entitled"Termination Provisions" Found on Page TERM UHIELIP-NC(07l06) 1 DocuSign Envelope ID: EE765B38-37EF-4402-B4E9-8B82F98E2EE8 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-905040 Effective Date: July 1,2015 Administrator: United HealthCare Services,Inc. Coverage specified herein is applicable only during the Policy Period from July 1, 2015 through June 30, 2016,and is further subject to all terms and conditions of this Policy. SPECIFIC EXCESS LOSS INSURANCE Benefit Period: Covered Expenses Incurred from January 1, 2014 through June 30, 2016 and Paid from July 1,2015 through June 30,2016. 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-NC(07/06) 2 SCHED DocuSign Envelope ID: EE765B38-37EF-4402-B4E9-8B82F98E2EE8 DEFINITIONS ADMINISTRATOR means a firm or person who has been retained by the Policyholder to provide administrative services on behalf of the Policyholder/Plan. BENEFIT PERIOD means the period of time specified in the Schedule of Benefits in which a Covered Expense must be Incurred by the Covered Person and Paid by the Plan to be eligible for reimbursement under this Policy. This period does not alter the Effective Date, Policy Period, or waive this Policy's eligibility requirements. COVERED EXPENSE means medical or other expenses under the Plan to which this Policy applies, as shown in the Schedule of Benefits, and which are not specifically excluded by the terms of this Policy. Covered Expense does not include any payment for the cost of administrating the Plan or other Policyholder contracted services. COVERED PERSON(S)means each person covered under the Plan. COVERED UNITS(S) means the types of Covered Units and the factors and premium rates for each type as shown in the Schedule of Benefits. EFFECTIVE DATE is the date set forth in the applicable Schedule of Benefits. INCURRED means with respect to medical services or supplies, the date on which the services are rendered or supplies are purchased by the Covered Person. PAY, PAID, PAYMENT means under the Specific Excess Loss, on the date the Policyholder's check of Payment of a Plan benefit is issued by the Administrator or when a credit of funds for Payment of a Plan benefit has been debited by the Policyholder's bank account. Under the Aggregate Excess Loss,on the date the Policyholder's check for Payment of a Plan benefit has been presented through the collecting bank and reported to the Administrator or when a credit of funds for Payment of a Plan benefit has been debited by the Policyholder's bank account. PLAN means the self-funded health care plan established by the plan sponsor to provide certain benefits to Covered Persons. PLAN DOCUMENT means the written document approved by the Policyholder. A copy of the Plan Document in effect on the Effective Date is attached to the application for Excess Loss Insurance. POLICY PERIOD means the specified period in the Schedule of Benefits, however beginning no earlier than the Effective Date of this Policy and continuing until coverage terminates in accordance with the Termination Provisions. SPECIFIC DEDUCTIBLE is set forth in the Schedule of Benefits. The Specific Deductible will apply separately to each Benefit Period. UHIELIP-NC(07/06) 3 DEF DocuSign Envelope ID: EE765B38-37EF-4402-B4E9-8B82F98E2EE8 REIMBURSEMENT PROVISIONS NOTICE OF COVERED EXPENSE The Policyholder authorizes the Administrator to file claims on its behalf under this Policy. The Policyholder authorizes the Company to reimburse Covered Expenses to the Administrator for deposit into the bank account maintained by the Policyholder for the funding of benefits under the Plan. PAYMENT BY PLAN While the determination of benefits under the Plan is the sole responsibility of the Policyholder,the Company reserves the right to interpret the terms and conditions of the Plan Document as it applies to this Policy. The Company will have the sole authority to reimburse or deny reimbursement under this Policy. SPECIFIC EXCESS LOSS INSURANCE The Schedule of Benefits indicates whether Specific Excess Loss Insurance is provided under this Policy. If, while this Policy is in effect, the Covered Expenses for a Covered Person for the applicable Benefit Period exceed the Specific Deductible, the Company will reimburse the Policyholder, subject to the terms and conditions of this Policy including the limits set forth in the Schedule of Benefits. The amount of the reimbursement will be equal to the Specific Percentage Reimbursable times the amount by which Covered Expenses exceed the Specific Deductible amount, but will not exceed the Maximum Specific Benefit.For purposes of determining whether such Maximum Specific Benefit has been exceeded, Covered Expenses Incurred or Paid in any other Policy Period under this policy are included. Covered Expenses for any Covered Person during the Policy Period will be determined according to the Benefit Period described in the Schedule of Benefits. If Specific Excess Loss Insurance terminates before the end of the Policy Period, the Specific Deductible will not be reduced. UHIELIP-NC(07/06) 4 REIM DocuSign Envelope ID: EE765B38-37EF-4402-B4E9-8B82F98E2EE8 PREMIUMS AND FACTORS PROVISIONS PAYMENT OF PREMIUMS For coverage to remain in effect, any subsequent monthly premium must be received by the Company by the first(1st)day of each month. Premiums are not considered Paid until the Company receives the premium payment. Premiums or other payments made by the Policyholder to their Administrator or Agent or Broker shall not be deemed or considered payments to the Company until actually received by the Company. The entire amount of the applicable premium shall be paid when due. The Company is not obligated to accept or apply any premium paid which is less than the entire amount due for any period. Premium payments shall be credited first to any past due and unpaid premium, in the order in which due. A late payment charge may be assessed for any premiums not received within fifteen (15) calendar days following the due date. A service charge will be assessed for any non-sufficient-fund check received in payment of premiums. The Policyholder will reimburse the Company for any attorney's fees and any other costs related to collecting delinquent premiums. GRACE PERIOD A Grace Period of thirty-one (31) days from the due date will be allowed for the payment of each premium after the first. During the Grace Period, the coverage will remain in effect provided the full premium is Paid before the end of the Grace Period. Should a premium otherwise due,not be Paid during the Grace Period,this Policy will terminate without further notice as of midnight on the last day for which premiums were Paid. PREMIUM AMOUNT The premiums will be calculated using rates determined by the Company as set forth in the Schedule of Benefits. The amount of total premium due each month is the sum obtained by multiplying the applicable premium rates shown in the Schedule of Benefits by the actual number of appropriate Covered Units. The Policyholder will be liable for any premium taxes assessed at any time against the Company beyond any taxes which may be payable on the premium received by the Company. All requests for adjustments, credits or refunds because of overpayment of premiums shall be reported, in writing,with accompanying detail within sixty(60)days after termination of the applicable Policy Period. The Company will not refund any portion of the premiums Paid if this Policy terminates during this Policy Period.The Company shall be entitled to reduce the reimbursements due the Policyholder under this Policy against any premiums due and unpaid, any overpayments or other reimbursements made in error or upon incorrect information,and any other amounts due the Company. PREMIUM RATE CHANGE The Company may change the Policyholder's premium rates for any of the following: a) the date when the terms of this Policy are changed; b) the date the Plan Document changes are accepted by the Company; c) the date the Policyholder adds or deletes subsidiary or affiliated companies or divisions; d) the date the number of Covered Units on any premium due date varies more than ten percent(10%) from the number of Covered Units as of the first month of the Policy Period. UHIELIP-NC(07/06) 5 PREFAC DocuSign Envelope ID: EE765B38-37EF-4402-B4E9-8B82F98E2EE8 TERMINATION PROVISIONS This Policy and coverage provided hereunder will terminate upon the earliest of: a) the premium due date of any premium which remains unpaid at the end of the Grace Period; b) the premium due date next following receipt by the Company of written notice from the Policyholder that this Policy is to be terminated; c) the date of termination of the Plan; d) the date the Policyholder suspends active business operations or dissolves; e) the end of the Policy Period;or f) the date the administrative services agreement with the Administrator is terminated. This Policy may also be terminated,at the Company's option on the earliest of: a) the last day of the second (2nd) consecutive month during which there are less than fifty-one (51) employees enrolled in the Plan,unless the Company agrees,in writing,to continue coverage;or b) the date the Policyholder fails to comply with the terms of this Policy;or c) on the Policy anniversary date by the Company giving sixty (60)days advance written notice that this Policy will end,or such other notice as required by law. The Company will not refund any portion of the premiums paid if this Policy is terminated during the Policy Period. SUBSEQUENT POLICY PERIOD PROVISIONS At the end of a Policy Period,this Policy may have a Subsequent Policy Period only by mutual agreement of the Policyholder and the Company. The Subsequent Policy Period may be subject to new premium rates, factors,new underwriting terms,new Benefit Period and other new Policy terms. The terms and conditions for a subsequent Policy Period will be evidenced by the issuance of a new Schedule of Benefits by the Company,which shows the new premium rates,Benefit Period and other new terms. UHIELIP-NC(07/06) 6 TERM DocuSign Envelope ID: EE765B38-37EF-4402-B4E9-8B82F98E2EE8 GENERAL PROVISIONS ADMINISTRATOR The Policyholder may retain an Administrator to act as an agent for the Policyholder in performing any or all of the duties as designated by the Policyholder. Without waiving any of its rights under this Policy, and without making the designated Administrator a party to this Policy, the Company agrees to recognize the Administrator as an agent of the Policyholder. The Policyholder will immediately notify the Company in writing if the agreement between the Policyholder and the Administrator terminates. ASSIGNMENT The Policyholder may not assign the Policyholder's interest in or reimbursement under this Policy,and the Company will not recognize any such assignment. AUDITS The Company will have the right: (a) to inspect and audit all records and procedures of the Policyholder and Administrator, developed and maintained for the Plan, that are applicable to the administration of this Policy; and (b) to require, upon request, proof satisfactory to the Company that Payment has been made to the Covered Person or the provider of such services or benefits which are the basis for any Loss by the Policyholder hereunder. CHANGES TO THE PLAN DOCUMENT If the Plan Document in effect on the Effective Date is subsequently amended,notice of the amendment will be given to the Company prior to the effective date of the change. If the Company does not give written acceptance of the amendment, the Company will only provide coverage under this Policy consistent with the Plan Document prior to amendment.The Company's reimbursement will be made according to the amended Plan,once the notice is received and accepted. CHANGES TO THE POLICY Only the President, a Vice President, or the Secretary of the Company have the authority to alter this Policy,or to waive any of the Company's rights and then only in writing.No such alteration of this Policy shall be valid unless endorsed and attached to this Policy.No agent,broker,or Administrator has the authority to alter this Policy or to waive any of its provisions. CLERICAL ERROR Clerical errors, whether by the Policyholder or by the Company, in keeping or transmitting any records pertaining to the coverage, will not invalidate or limit coverage otherwise validly in force nor continue coverage otherwise validly terminated. Clerical error does not include any failure of the Policyholder, the Administrator or any agent of the Policyholder: (a) to comply with the requirements relating to notice of claims or payment of claims; or(b)to disclose underwriting information requested by the Company,whether or not intentional and regardless of the actual knowledge of the person providing the information. CONFORMITY WITH LAW If any provision of this Policy is contrary to any law to which it is subject, such provision is hereby amended to conform to the minimum requirements of such law. ENTIRE CONTRACT The Entire Contract between the Company and the Policyholder will consist of this Policy, Schedule of Benefits, application, approved amendments or endorsements, and a copy of the Plan Document,which is on file with the Company. INSOLVENCY Nothing in this Policy shall either relieve an insolvent or bankrupt Policyholder from the obligation to pay premiums when due or delay or abate cancellation of this Policy for failure to do so. The insolvency, bankruptcy, financial impairment, receivership, voluntary plan of arrangement with creditors, or dissolution of the Policyholder or the Policyholder's Administrator will not impose upon the Company any liability other than the liability defined in this Policy. In particular, the insolvency of the Policyholder will not make the Company liable to the creditors of the Policyholder,including Covered Persons under the Plan. LEGAL ACTION The Policyholder cannot file suit until ninety (90)days after the date on which proof of loss is given to the Company. The Policyholder cannot file suit more than three (3)years after the date on which the Policyholder must give the Company proof of Loss. LIABILITY The Company will have neither the right nor the obligation under this Policy to directly pay any Covered Person or provider of professional or medical services. The Company's sole liability is to the Policyholder,subject to the terms and conditions of this Policy.Nothing in this Policy shall be construed to UHIELIP-NC(07/06) 7 GEN DocuSign Envelope ID: EE765B38-37EF-4402-B4E9-8B82F98E2EE8 permit a Covered Person to have a direct right of action against the Company. The Company will not be considered a parry to the Plan of the Policyholder,or to any supplement or amendment to it. MISSTATED DATA, CONCEALMENT,FRAUD The Company has relied on the information provided by the Policyholder, the Administrator or any agent of the Policyholder, in the issuance of this Policy, or for any Subsequent Policy Period.In the event of a misrepresentation,concealment or omission of a fact,or a mistake of fact (whether or not a mutual mistake), any of which materially affect the underwriting, premium,rating or terms and conditions of this Policy,the Company may,at its option: (a) increase premium rates, attachment points and/or otherwise change the terms and conditions of this Policy. Such increase or change to be effective retroactively to the Effective Date or as of any premium due date thereafter,or (b) terminate this Policy as of the next premium due date. The Company may declare this Policy null and void in its inception if,whether before or after a claim, the Policyholder, Administrator or any agent of the Policyholder has willfully or intentionally misrepresented, concealed, omitted any material fact affecting terms, conditions, or underwriting of this Policy. In such event, the Company's liability under this Policy shall be limited to refunding premiums paid by the Policyholder after deducting therefrom the amount of any Covered Expenses reimbursed by the Company to the Policyholder prior to the date of termination. If the amount of the Covered Expenses reimbursed by the Company to the Policyholder exceeds the premiums paid by the Policyholder, the Policyholder shall pay the Company the difference within thirty (30) days of the date the Company notifies the Policyholder of such difference. NOTICE OF COMPLAINT, APPEAL, LEGAL ACTION As a condition precedent to the Company reimbursing the Policyholder in any settlement or judgment for a disputed Covered Expense, the Policyholder shall immediately inform the Company of any notice of appeal, notice of legal action, or objection,demand or complaint which the Policyholder received regarding any Covered Expense that may be reimburse under this Policy. OTHER COVERAGE The reimbursement provided by this Policy is in excess of other coverage such as group insurance,excess insurance,insurance,plan benefits, including insurance or plan benefits established by any federal,state,or local law. PARTIES TO THE POLICY The parties to this Policy are the Policyholder and the Company. The Company's sole liability under this Policy is to the Policyholder. This Policy does not create any right or legal relation between the Company and a Covered Person under the Plan. This Policy will not be deemed to make the Company a party to any agreement between the Policyholder and the Administrator. POLICYHOLDER REQUIREMENTS The Policyholder agrees to provide funds for Payment of all eligible expenses under the Plan.If the Policyholder fails to provide funds for timely Payment: (a)coverage under this Policy will immediately terminate; and (b) any Aggregate and/or Specific Deductible will be deemed not satisfied. RECORDS The Policyholder will maintain records of all Covered Persons under the Plan during the Policy Period and for a period of seven(7)years after the end of the Policy Period. The Policyholder will make all such records available to the Company as needed to evaluate its liability under this Policy. The Policyholder will maintain a separate record of any and all amounts Paid in excess of benefits eligible under the Plan. SEVERABILITY CLAUSE Any clause deemed void,invalid,or otherwise unenforceable,whether or not such a provision is contrary to public policy,will not render any of the remaining provisions of this Policy invalid. TERMINATION OF THE POLICYHOLDER'S PLAN The Policyholder will immediately notify the Company,if the Plan is terminated. UHIELIP-NC(07/06) 8 GEN DocuSign Envelope ID: EE765B38-37EF-4402-B4E9-8B82F98E2EE8 WAIVER Failure of the Company to strictly enforce its rights under this Policy shall not waive any such right,regardless of the frequency or similarity of the circumstances. UHIELIP-NC(07/06) 9 GEN DocuSign Envelope ID: EE765B38-37EF-4402-B4E9-8B82F98E2EE8 GENERAL EXCLUSIONS PROVISIONS The Company will not reimburse the Policyholder for any of the following: (a) Any payment which does not strictly comply with the terms and conditions of the Plan Document; (b) Any payment or expense caused by or resulting from war,whether or not declared, any act or hazard of war,while a Covered Person is a member of any kind of military force or auxiliary unit engaged in that war; (c) Any payment for litigation costs and expenses, extra-contractual damages, compensatory damages, interest, exemplary and punitive damages or liabilities, including but not limited to those resulting from negligence,intentional wrongs,fraud,bad faith or strict liability on the part of the Policyholder, Plan,Administrator or any agent or representative of the Policyholder,Plan or Administrator; (d) Services or supplies for the treatment of an Occupational Injury or Sickness which are paid under the North Carolina Worker's Compensation Act only to the extent such services or supplies are the liability of the employee, employer or workers' compensation insurance carrier according to a final adjudication under the North Carolina Worker's Compensation Act or an order of the North Carolina Industrial Commission approving a settlement agreement under the North Carolina Workers' Compensation Act. UHIELIP-NC(07/06) 10 EXCL DocuSign Envelope ID: EE765B38-37EF-4402-B4E9-8B82F98E2EE8 UNITEDHEALTHCARE INSURANCE COMPANY A Stock Company 185 Asylum Street,Hartford,Connecticut Phone: 1-860-702-5000 APPLICATION FOR EXCESS LOSS INSURANCE The undersigned Applicant requests the Excess Loss Insurance Benefits shown herein and provided by UnitedHealthcare Insurance Company,and agrees to be bound by the terms and provisions of the Excess Loss Insurance Policy. Full Legal Name of Applicant: Orange County Address: 200 South Cameron Street,Hillsborough,NC 27278 Key Contact: Diane Shepherd Telephone: 919-245-2558 Tax ID: Applicant is a: Local Government Nature of Business of the Group to be Insured: Local Government Requested Effective Date: July 1,2015 Total number of eligible persons: Employees: 869 Retirees: 153 Are retirees covered: Y Agent or Broker: Arthur J. Gallagher&Company SS No.or Tax ID: Address: 4064 Colony Road, Suite 450,Charlotte,North Carolina 28211 SPECIFIC EXCESS LOSS INSURANCE: Benefit Period: Covered Expenses Incurred from January 1,2014 through June 30,2016,and Paid from July 1,2015 through June 30, 2016. Specific Deductible per Covered Person: $100,000 Specific Percentage Reimbursable: 100% Maximum Specific Benefit per Covered Person:Unlimited Covered Expenses Under Specific Excess Loss: • Medical • Stand Alone Prescription Drug Program Specific Excess Loss Premium: $107.03 per subscriber per month It is understood and agreed by the undersigned that: a. The statements,declarations and representations made in this Application,any request for proposal,the underwriting information provided by or on behalf of the undersigned and the Plan Document are the undersigned's representations; that any Policy is issued in reliance upon the truth of such statements,declarations, and representations; and that such statements,declarations,and representations will form a part of the Excess Loss Insurance Policy. Any inaccuracy in such information or failure to disclose any such information, including all claims or possible claims, paid or pending, or which the Employer should otherwise know about,if discovered later,can result in rejection of this Application,or can change the terms,conditions or premiums,or can void coverage. b. As a condition precedent to the approval of this Application, the undersigned shall furnish to the Company a copy of the executed Plan Document within 90 days after the date of this application describing the benefits provided by the Plan, which shall be kept on file in the office of the Company. If the Company does not receive the Plan Document within 90 days, the UHIAPP(12/01) DocuSign Envelope ID: EE765B38-37EF-4402-B4E9-8B82F98E2EE8 Company may refund all premium and the Application shall have been null and void when signed. No Excess Loss Insurance will be effective nor reimbursement made unless a Plan Document is received and accepted by the Company. C. The Company will evaluate the undersigned's risk, as requested by this application, the underwriting data received and represented by the Plan and may require adjustments of rates,factors,and/or special limitations. d. Any coverage resulting from this Application shall be subject to the terms and provisions of the Policy herein applied for. Coverage shall become effective on the date specified in this Application if all requirements of the Company,including the Plan Document and the underwriting requirements have been met and the required premiums paid. e. The receipt by the Company of the first month's premium and deposit of any check drawn in connection with this Application shall not constitute an acceptance of liability. In the event the Company does not approve this application, its sole obligation shall be to refund such sum to the undersigned. The undersigned has read the entire Application for Excess Loss Insurance and understands that the insurance requested herein is not in effect until this Application is approved and accepted by the Company. Full Legal Name of Applicant: Bonnie Hammersley DocuSigned by: Signature of Authorized Person: �jOV�,l�t't- ( mmvsb )637994B755E477... Print Name: Bonnie Hammersley Title: County Manager Date: 8/5/2015 Signature of Agent or Broker: DocuSigned by: vac 6A B71 B11 . Printed Name of Agent or Broker: Eric Black License No. FRAUD WARNING NOTICES: (Please review notice that applies in your state) For applicants in Arkansas and Louisiana: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance,is guilty of a crime and may be subject to fines and confinement in prison. For applicants in Colorado: It is unlawful to knowingly provide false, incomplete or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment,fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds, shall be reported to the Colorado division of insurance within the Department of Regulatory Agencies. For applicants in District of Columbia: WARNING: It is a crime to provide false or misleading information to an insurer for purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the application. UHIAPP(12/01) DocuSign Envelope ID: EE765B38-37EF-4402-B4E9-8B82F98E2EE8 For applicants in Florida: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false,incomplete,or misleading information is guilty of a felony of the third degree. For applicants in Kentucky,New Mexico,Ohio,and Pennsylvania: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties. For applicants in Maine,Tennessee and Virginia: It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company.Penalties may include imprisonment,fines,or a denial of insurance benefits. For applicants in New Jersey: Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties. For applicants in all other states: If is a crime to knowingly provided false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company.Penalties may include imprisonment,fines,or a denial of insurance benefits. UHIAPP(12/01) DocuSign Envelope ID: EE765B38-37EF-4402-B4E9-8B82F98E2EE8 CERTIFICATE OF LIABILITY INSURANCE DATE 04124//2014 2014 /YYYY) 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 Marsh USA Inc. NAME: 333 South 7th Street,Suite 1400 AANNo Exl FAX No): Minneapolis,MN 55402-2400 EMAIL Attn:Healthcare,AccounlsOSS @marsh.com Fax 212.948-1307 ADDRESS: INSURERS AFFORDING COVERAGE NAIL# 401115-OLD-PL5M-14-16 INSURER A:Old Republic Insurance Company 24147 INSURED INSURER B: UNITEDHEALTH GROUP 9900 BREN ROAD EAST MN008-W345 INSURER C: MINNETONKA,MN 55343 INSURER D INSURER E: INSURER F: 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. INSR TYPE OF INSURANCE ADD SUBR POLICY EFF POLICY EXP LIMITS LTR POLICY NUMBER MMIDD/YYYY MM/DD/YYYY GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY D TO( a TED PREMI SES Ea occurrence) $ CLAIMS-MADE F-1 OCCUR MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ POLICY PRO—$ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS HIRED AUTOS NON-OWNED PROPERTY DAMAGE $ AUTOS Per accident $ UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LAB HCLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION WC sTATU- oTH- AND EMPLOYERS'LIABILITY YIN I ER ANY PROPRIETORIPARTNERIEXECUTIVE❑ N!A E.L.EACH ACCIDENT $ `: OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ II yes,describe under bESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ A Managed Care MWZZ302190 05/01/2014 05/01/2016 Each Claim $5,000,000 Professional Liability/E&O RETRO DATE:111177 Annual Aggregate $5,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,it 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 r.- ©1988-2010 ACORD CORPORATION, All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD 1 :