HomeMy WebLinkAbout10-19-2015 AGENDA MODIFICATION (PDF ONLY)WASHINGTON
TO: Members of the City Council
Mayor Backus
Department Directors
FROM: Danielle Daskam, City Clerk
SUBJECT: Agenda Modification
DATE: October 16, 2015
The October 19, 2015, City Council Meeting agenda is modified to add the
following discussion item:
XI. Resolutions
A. Resolution No. 5177
A Resolution of the City Council of The City of Auburn,
Washington, authorizing the Mayor to execute an agreement
between the City of Auburn and Premera Blue Cross for health
care coverage
RESOLUTION NO. 5 1 7 7
A RESOLUTION OF THE CITY COUNCIL OF THE CITY OF
AUBURN, WASHINGTON, AUTHORIZING THE MAYOR
TO EXECUTE AN AGREEMENT BETWEEN THE CITY OF
AUBURN AND PREMERA BLUE CROSS FOR HEALTH
CARE COVERAGE
WHEREAS, the City provides, among its employee benefits, health care
coverage for City employees and their families; and
WHEREAS, the costs of health care coverage has risen in recent years,
prompting the City to explore alternatives; and
WHEREAS, the City has the opportunity to provide comparable health care
coverage for those employees and their families currently covered by the Association of
Washington Cities Employee Benefit Trust (AWC) health care plans at a cost savings;
and
WHEREAS, it is therefore appropriate for the City to consider engaging in
contracts with Premera Blue Cross to provide those health care services currently
provided by AWC.
NOW, THEREFORE, THE CITY COUNCIL OF THE CITY OF AUBURN,
WASHINGTON, HEREBY RESOLVES as follows:
Section 1. That the Mayor is hereby authorized to execute an agreement
between the City and Premera Blue Cross for health care coverage, which agreement
shall be in substantial conformity with the agreement attached hereto as Exhibit A and
incorporated herein by this reference.
Section 2. That the Mayor is authorized to implement such administrative
procedures as may be necessary to carry out the directives of this legislation.
Resolution No. 5177
October 15, 2015
Page 1 of 2
Section 3. That this Resolution shall take effect and be in full force upon
passage and signatures hereon.
Dated and Signed this day of , 2015.
CITY OF AUBURN
NANCY BACKUS. MAYOR
ATTEST:
Danielle E. Daskam, City Clerk
APPROVED AS TO FORM:
lb-a6ilallb. He City Attorney
Resolution No. 5177
October 15, 2015
Page 2 of 2
P.O. Box 91060
Seattle, WA 98111 -9160 Exhibit
GROUP MASTER APPLICATION
51 OR MORE ELIGIBLE EMPLOYEES
PREMERA
"All r
Application Is made to Prelnem Blue Cross (hereafter referred to as "we;"
'us," or "our") for a new Health Care Contract, the provisions of which shall be
made available to all eligible classes of employees.
Your group cannot be enrolled prior to our receipt date of this completed and
signed application, which must be accompanied by the initial subscription GROUP ID
charge payment. This application and subscription charge payment must be
received no less than 10 days prior to the requested effective date. (Completed by Premera Blue Cross)
1. PURPOSE
® New Group: Complete this application and submit with enrollment forms, and the first month's payment prior to the effective date of coverage
D Renewal: Complete this application and Benefit Selection Report In Its entirety.
D Other
Effecllve Date: From: 1/1 /2016 To: 12/31/2016 Annual Contract Renewal Month ,tanuary
2. GROUP INFORMATION
A. Legal Narne City of Auburn
Common Name Note: Required If Legal Name oxceeds 50 characters and spaeos, ofhorMso, optional.
I I I I
Physical Address 25 Nest Main
City Auburn State WA ZIP 9811111 County King
B. Mailing Address ® Same as Physical Address D Separate Address, complete the following
C. Billing Address ® Some as Mailing Address ❑ Same as Physical Address D Separate Address, complete the following:
Street/ P.O.
Billing Contact Person D Mr. ® Mrs. D Ms. Ronda Stella Title Payroll & AP Supervisor
Phone No (253)804 -5018 Fax No ( ) - E-mail Address rsfella a aubnrncva.gov
D. Group Contact Person ® Mr. D Mrs. D Ms. Aaron Barber Title Comp & BR Manager-
Phone No (253)853 -5093 Fax No.( ) E -mail Address ahnl'b Cl' /l allh ll l'IIWa.gUV
E. Do you use a COBRA Administrator? D No ® Yes, complete the following: D Some as Billing Address and Contact Person
(same contact as section 2C & 2D)
COBRA Administrator Billing Address BCC Accounting UBpartnlent T1vc, Robinsoll Plaza, Suite 200
City Pittsburgh Slate PA ZIP 15205 County
COBRA Administrator Contact Person D Mr. ® Mrs (] Ms Lnaren Causer Title Data Service Supervisor
Phone No. (412)446-4611 Fax No. ( ) E -mall Address IgansvverQa hcilxceLconi
F. Employer Identification Number (EIN) 91- 6001228
Type of Business Munloipality SIO # 9199 NAICS 11921190
O. Is the group a subsidiary of or affiliated with another company or headquartered outside the State of Washington? ONO D Yes, complete the folowing
ZIP
H. In the past 36 months has the group or any affiliated entity
filed for protection or operated under Foderal / Stato Bankruptcy laws? ® No D Yes
In the past 36 months has any creditor flied or threatened to file a
petition requesting the group or any affiliated entity to be put into bankruptcy? ® No D Yes
I. Is workers compensation coverage provided for all employees? ® Yes O No, please list employeas nol covered and reason:
008715 (01.2014)1 GROUP MASTER APPLICATION 51+ PAGE 1 OF 5
An!ndependent Llcensoe of the Blue Cross Blue Shield Assodal'mn
3. EMPLOYEE ELIGIBILITY REQUIREMENTS
If all of your employees must work the same hours, meet the same probationary period and will have the same benefle optlons available to them,
complete section A (omit B), then continue to C, D and E.
If you are differentiating your employees by class (i.e.. Managers, Hourly, etc.) complete section B (omit A), then continue to C, D and E.
A. All Employees In One Class
1. Minimum Work Hours
All employees who normally work a minimum of 30 hours' per week and have satisfied the probationary period are eligible.
'Note: Employees must walk at toast 20 hours per week to quality for health coverage. The group may choose to set file m6uroum number c f work hours
per week higher for employees to be allglblo,
2. Probationary Period Information
All eligible employees are effective on the'.
❑ 1st of the month following Or ❑ Next day following:
❑ 30 days ❑ 60 days ❑ _ Number of days from (enter date)*
'Note: Probationary period cannot be more than 60 days.
® tat of the month following dale of hire ® Exact date of hire
B. Employees Differentiated by Class
Minimum Work Hours and Probationary Period Information
Only employees in a specific class or classes who normally work the specified
minimum hours per week that have met the probationary period are eligible.
Complete the minimum work hours' and probationary period Information for
each designated class of employee. If you have differentiated your benefit
coverage selection by class of employee on your Benefit Coverage Selection Worksheet – those same Gasses must be represented
*Note: Employees must work at least 20 hours per week to quality for health coverage. The group may choose to set the minimum
number of work hours
per week higher for employees to be eligible.
❑ Management (M)
❑ Salaried (S)
❑ Hourly (H)
❑ Part-time (P)
❑ Full -time (F)
❑ Other (0) Please
specify _
Minimum hours
Minimum hours
Minimum hours
Minimum hours
Minlnmm hours
Minimum hours _
❑ I" of the month
❑ 1" of the month
❑ is of the month
❑ 1" of the month
❑ 1" of the month
❑ 1" of the month
following:
following:
following:
following:
following:
following:
❑ Date of hire
❑ Date of hire
❑ Dale of hire
❑ Date of hire
❑ Dale of hire
❑ Date of hire
❑ 30 days
❑ 30 days
❑ 30 days
❑ 30 days
❑ 30 days
❑ 30 days
❑ 60 days
❑ 60 days
❑ 60 days
❑ 60 days
❑ 60 days
❑ 60 days
❑ Exact date of hire
❑ Exact date of hire
❑ Exact date of hire
❑ Exact dale of hire
❑ Exact date of hire
❑ Exact date of hire
C. Waive Probationary Period —to be completed by New Groups Only
$- Waive the probationary period on alt current qualifying employees.
❑ Apply the probationary period to all employees (current qualifying employees must satisfy the balance of the above probationary period).
D. Coverage will end:
N Last day of the month for which subscription charge Is paid
❑ Other
E. Domestic Partners
Domestic Penner coverage Is standard for all fully Insured groups Win 51 or more employees. All domestic partners, Including same sex, opposite sex,
and state. registered will be considered ellglhle dependents. Domestic partner eligibility will Include eligibllltyfor COBRA continuation coverage.
If you would like to limit domestic partner coverage to slate- registered domestic partners and/or choose not to extend COBRA coverage for domestic
partners, please contact your Premera sales representative. If yourgroup Is self- funded, please contact your sales representative for your options,
008715 (01 -2014) GROUP MASTER APPLICATION 51+ PAGE 2 OF 5
4. EMPLOYEE ENROLLMENT
A. Total number of employees G. Total number of retirees eligible for benefits 56
on payroll regardless of hours worked 554
R, Total number of COBRA/Continuatlon of Coverage
Note: For 48 and 4C count each employee in only ONE category. subscribers 3
B. Employees not eligible to enroll I. Do you have eligible employees employed outside the State
of Washington?
1. Employees who work less than the minimum
hours per week (as specified In section 3A) 20 ® No ❑ Yes, complete the following table:
2. Employees who are temporary or seasonal 129 Number of
Stato /Country Employees
3. Employees who are In a probationary period 1
4. Employees who are not In a covered class
(employees not specified as eligible In 3A) 0
Total 4B 150
C. Employees not enrolling due to coverage under:
1. A Government plan
(e.g., Medicare, CHAMPUS/Trlcare, Military) 0
2. Other group coverage 35
3. A collective bargaining agreement (Union) 89
Total 4C 124
D. Total number of employees eligible to enroll
(section 4A - 48 - 40 280 _
E. Eligible employees waiving enrollment without other coverage 0
,1, Calculated Actual % of participation
F. Total numberof eligibleemployeas enrolling (sec6'on 4D -4A) 280 (Completed by Premera Blue Cross)
5. EMPLOYEE PARTICIPATION AND EMPLOYER CONTRIBUTION
A. Minimum Employee & Dependent Participation Requirements — TO BE COMPLETED BY PREMERA
Minimum eligible employee participation requirement is % I Minimum eligible dependent participation requirement is %
S. Employer Contribution Requirements - TO BE COMPLETED BY EMPLOYER
Please Note: Waivers of coverage are NOT allowed for eligible employees of non - contributory groups. If dependent coverage Is also
non - contributory, no waivers of coverage are allowed.
1, Effective date of Contribution: 1/1/16 (mon;h/ day /year)
2, The employer will contribute the following percentage or dollar amount toward the cost of eligible employee and dependent coverage:
Please Note: If you differentiate contributions by class of employee, those same classes must be represented here.
Medical Dental Vision
Employee: 100 Ida n/a
Spouse / Domestic Partner: 90
Dependent Child (1 child) 90
Dependent Children (2 or more) 90
C. Employer Contribution Changes - Impact on Grandfathoring
❑ Employer Contribution towards the cost of any tier of coverage has not been decreased by more than 5 percentage points since
March 23, 2010
❑ Employer Contribution towards the cost of any tier of coverage has decreased by more than 5 percentage points since
March 23, 2010
Note: If the Employer contribution towards the cost of any tier of coverage has decreased by more than 5 percentage points since
March 23, 2010, the plan ceases to be grandfathered.
Please Note: We reserve the right to review payroll records or comparable reports to ensure that eligibility and enrollment requirements are met.
008715 (01.2014) GROUP MASTER APPLICATION 51+ PAGE 3 OF 5
6. FEDERAL REQUIREMENTS
Helpful Hint: We strongly urge you to consult legal counsel In answering the questions below. The summaries below are not intended
to be or to replace legal advice on your particular group. It Is the group's responsibility to inform Premera immediately if facts change
which would cause the group's answers below to change.
A. Is the group subject to the federal Medicare Secondary Payer (MSP) laws that prohibit discrimination against Individuals with group coverage
based on their (or a spouse's) current employment status who have Medicare due to age?
1. E Yes. This plan will pay primary to Medicare as required by federal law.
❑ No. Under 20 employees.
2. Please also provide the number of employees who now meet Medicare's definition of "employee.
Helpful Hint These laws do not apply to any employer who did not employ 20 employees or more for each working day in each of 20 or more colander
weeks in either the current orpreceding calendar year. For these small gmup plans, Medicare pays primary to the group plan.
"Employees" include all full -time and pail -time employees as well as those employees on disability and subject to FICA taxes. Also count leased
employees if they would be counted as employees under §414(n)(2) of the Internal Revenue Code (IRC), and count employees employed by an "affiliated
sonelce group" under IRC §414(m) or by employers considored to be a "single employer" under IRC §52(a) or (b).
B, Is the group subject to COBRA?
E Yes
❑ No Give the legal reason for exemption:
Helpful Hint: Generally, these laws apply to any non - church employer that employed 20 or more employees on at least 50% slits working days in the
preceding calendar year.
"'Employees" are full -time and part-time common -law employees. Soil - employed warkers as defined in IRC §401(c)(1), corporate directws, or
independent contractors should not be counted unless they qualify as common -law employees. "Employees" may also include leased employees who
qualify as common -law employees. Please we COBRA regulations at 26 CFR § 54.4960B -2 Q/A 5 for guidance on counting a part-time employee as a
fraction of a full -time employee.
C. is the group subject to the federal Medicare Secondary Payer (MSP) laws that prohibit discrimination against individuals with group coverage
based on their (or a family member's) current employment status who have Medicare due to disability?
1. E Yes. This plan will pay primary to Medicare as required by federal law.
❑ No. Under 100 employees.
2. Please also provide the number of employees who now meet Medicare's definition of "employee.
Helpful Hint: Generally, these laws apply to any employer that employed at least 100 employees on 50% or more of its working days In the preceding
calendar year. Seethe helpful hint in 6A above for a definition of "employee "for this purpose.
D. Is the group subject to ERISA?
❑ Yes. Enter the month the ERISA plan year ends: Month
E No. Give the legal reason for exemption: E Government or Public Plan ❑ Church Plan
❑ Other, please specify:
Helpful Hint: Generally, ERISA applies to all employer health plans except governmental, public or church plans. Non - profit status alone does not exempt
an employer from CRISA.
7. CURRENT COVERAGE INFORMATION
A. Is this Premera Blue Cross plan intended to replace any existing coverage? ❑ No, go to section 7B E Yes, complete the following:
1. Name(s) of current Medical carrier(s)
2. Name(s) of current Dental carrier(s)
n/a
Does your current dental coverage include orthodontia? ❑ No ❑ Yes
0. Name(s) of current Vision carner(s)
]I/,I
Proposed termination date 12/31/2015
Effective date of dental coverage
Proposed termination date
If Yes, effective date of orthodontia coverage
Proposed termination date
8. Are you offering a plan from a carrier other than Premera Blue Cross? ❑ No, go to section 8 E Yes, more than one carrier's plan is offered:
Names) of other Medical carriers
Indicate if other plan Is an HSA. HSA?
E No
Group liealth ❑ Yes
❑ No
❑ Yes
❑ No
❑ Yes
Name(s) of other Dental carrler(s) Name(s) of other Vision carrier(s)
o/a
008715 (01 -2014) GROUP MASTER APPLICATION 51+ PAGE 4 OF 5
8. CERTIFICATE OF HEALTH COVERAGE
Requirement: The Health Insurance Portability and Accountability Act (HIPAA) requires that a Certificate of Hoallh Coverage must be provided
to members terminating from the health plan upon their request.
A. Do you want Premera Blue Cross to distribute Certificates of Health Coverage?
❑ No, the group (or the group's designee) will produce and distribute the Certificates of Health Coverage. Go to section 8.
® Yes, go to section 86.
B. Premera will send the certificates directly to the member, unless the group requests that we send the certificates directly to the: ❑ Group
9. GROUP MATERIALS
Important note: Electronic copies of benefit booklets are available online at www.oremera.com. Please Indicate If you would like printed
copies sent.
Printed copies should be sent lo: Producer: ❑ Contract ❑ Benefit Booklef(s)
Group Administrator: ❑ Contract ❑ Benefit Booklets) Number of booklets:
10. PRODUCER AGREEMENT TO CONTRACT
A. You, the producer(s), certify that you have met with the group submitting this agreement and that you have fully explalned its contents. You
have discussed cove e, ell gibllily, any pre - existing condition walling periods, the effect of misrepresentations, termination provisions and
subscription charge 111111111 /g'gadgln i I,
Producer SlenaAueN t fhTh /`li Y,L"n\n S Date /(]h Lll i.7—
E-mail Address nschiroRbblacoma.com Name of Flrm /Agency Brown & Brown of WA
Effective Date Producer Is Appointed for this Group 1/1/2016
Commission: ❑ PEPM ® 0 % ❑ Scale
B. ❑ Split Commission
Secondary Producer Name
Secondary Producer Number
Commissions are split between the primary and secondary producer as follows (e.g., 50% / 50 %): Primary 0 % I Secondary %
11. GROUP AGREEMENT TO CONTRACT
You, the group named In section 2 of this application, understand and agree to the following.
A. This application becomes part of the contract to provide health care coverage after:
• The application Is signed by you;
• The application is received and approved by us: and
• We receive the Initial month's subscription charges,
You may not assign this contract without our written consent. Any attempt to do so will not have any binding effect on us. You agree to
promptly deliver materials and notifications, including benefit booklets, received from us to all covered employees, You also agree to provide
notification regarding the plan's waiting period and special enrollment rights to all eligible employees before their enrollment. You attest to have
read this application, and certify that all statements are true and complete. You agree to the terms and obligations stated In this application. It Is
understood that provisions of the Health Care Contract, Including subscription charges, may be amended or changed front time to time, upon
our notice to you. All prior applications, to the extent that you have not made changes to them in this application, remain In full force and effect.
The producer listed in section 10 will remain effective untll written notice Is given by either party. We are authorized to pay, on your behalf,
commission, if any, for which you are liable to the above named producer,
B. You may elect to allow the producer listed above to act as a group benefit administrator beginning on the group's effective date. This means
that the producer /administrator will be able to access membership and billing functions, and obtain Information about group members via the
Web on behalf of the group. These functions may Include, but are not limited to:
• Reinstate Terminated Members • Inquire on Invoice • Order ID Cards for an Individual or Whole Family
• Request Invoice • Inquire on Eligibility • View Group Demographic Information
• Search for a Member • Enroll a Member • Cancel a Member
• View Benefit Detail
Do you elect and authorize Premera Blue Cross to provide such Information to the producer? ❑ No ❑ Yes
C. I affirm that this group has a physical location in the Slate of Washington, and I am authorized to sign on behalf of the group.
Signature of Group's Representative Date
Group's Representative (Print Name) Rob Roscoe Title Huuau Resources Director
Please note: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of
defrauding the company. Penalties include imprisonment, fines, and denial of insurance benefits.
TRACKING INFORMATION —TO BE COMPLETED BY PREMERA BLUE CROSS
Date Received by Sales Information Complete _ ❑ Yes._ ❑ No__ Date Missing Information Received
Account ManaoerlSales Execu'ive Extension Rep. Code
Sales Support Contact Extension Sales Distribution
008715 (01 -2014) GROUP MASTER APPLICATION 51+ PAGE 5 OF 5
CC
New Group Notification Form
Welcomel Thank you for choosing Benefit Coordinators Corporation as your benefit administration partner. This form is designed to help us confirm the services we are to
provide and the fees that have been agreed upon, and to provide important basic information that will help us prepare for a smooth implementation. In order to begin
implementation, please complete, date and have this form signed by both the employer and broker, and return along with applicable set -up feels). If you have any questions or
would like assistance, please contact your sales representative.
Employer Signature: Date:
Broker Signature: Date:
FOR BCC USE ONLY
Group Number Assigned:
Producer:
NAE:
HNAIBCI; ❑ YES ❑ NO
Benefit Coordinators Corporation (BCC) I Two Robinson Plaza, Suite 200, Pittsburgh PA 15205 1 412,276, 1111 l www.benxrel,com I rev. 20150316
L General Information
Effective Date: 111116
I N of Healthcare Enrolled: 266
8 of Benefit Eligible: 315
Full Legal Name: City of Auburn
Street Address: 25 West Main
City: Auburn
ST:WA Zip: 98001
Contact NameRitle: Aaron Barber ! Benefits and Compensation Manager
Phone: 253 -804 -5093
(exL)
E-mail: abarber @auburnwa.gov
Fax:
EIN Number: 91- 6001228
Slate Where Tax ID Filed: WA
Broker ContacUTitle: Natalie Schlro
Broker
-
Agency: Brown & Brown of WA
Phone: 253 -396 -5602
(ext.)
Fax:
E -mail: nschiro @bbtacoma.com
Cell: 253 - 820 -8500
Street Address: 1145 Broadway Suite 700
111. Administration
® Consolidated Invoicing (complete attached page)
City: Tacoma
Services: (Pie
❑ HRA
ST:WA Zip: 98401
se check all that apply.)
❑ MRA (please attach benefit gild and employer reimbursement level)
® COBRA
I 8 of people on COBRA now
❑ HSA
❑ FSA or ❑ FSA with Debit Card
Annual Maximum $
❑ Retiree Billing
❑ Dependent Audit
❑ Self- Funded Medical
❑ Parking
❑Transit
❑ Expanded Call Center
❑ Self- Funded Dental
❑ Self- Funded Vision
❑ Other
❑Other
❑ TotalWorks Healthcare Reform Services
❑ ACAWorks
❑ Other
❑ Other
WEB TOOL: ❑ BenXcel Inquiry ❑ BenXcel Compare & Pay ❑ BenXcel
Structure
EMPLOYEE COMMUNICATIONS PORTAL: ❑ Benergy ❑ PlanSource
Employee Classes
IV, Client
CLASSES: Are there multiple classes?
® Yes ❑ No
It Yes, how many? 4
DIVISIONS: Are there multiple divisions?
❑ Yes ®No
If Yes, how many?
V -Up Fee
Set
Prior to the implementation of any administrative service being provided, please complete, sign and date this form.
Please include the set -up fee per applicable line of coverage as listed in the proposal. $'I
® Paid by Employer ❑ Paid by Broker
Employer Signature: Date:
Broker Signature: Date:
FOR BCC USE ONLY
Group Number Assigned:
Producer:
NAE:
HNAIBCI; ❑ YES ❑ NO
Benefit Coordinators Corporation (BCC) I Two Robinson Plaza, Suite 200, Pittsburgh PA 15205 1 412,276, 1111 l www.benxrel,com I rev. 20150316
Consolidated Invoicing Information (continued from Section 111)
A. COVERAGE: Please Indicate applicable carrier name(s). If there Is more than one plan design, use "Other" category.
Vera9e s �A
Ve P
rntr,�,
rrler
ve 2
❑
❑
❑
❑
23 Medical: Prenrem
❑
19
❑
❑
❑ ER Paid Dep. Life:
❑ Medical:
❑
❑
❑
❑
❑ ER Paid Dop A00.
LTD: Standard
1:1
❑
❑
❑
❑ Medical:
❑
❑
❑
0
❑ Dental:
❑
❑
STD: Standard
❑
❑
I@
❑ Dental:
❑
❑
❑
❑
❑ Chlro:
❑
❑
❑
❑
[D Vislon: VSP
❑
❑
❑
❑
❑ EE Assistance:
❑
❑
❑ Vision:
❑
❑
❑
❑
❑ Other:
❑
❑
❑
1:1
❑ Rx:
❑
❑
❑
❑
❑ Other:
❑
11
0 1-IfeStandard
❑
❑
ISI
0
❑ Other:
AD&D: Standard
❑
❑
0
0
❑ Other:
❑
❑
❑
❑
B. VOLUNTARY: Please indicate applicable carrier renta(s). It there Is more than one plan design, use "Other" category,
38ve a*
enter,
Weer"
Mersa
1�
52
, Carro
CA net ^'n
Cdverae�
G] Vol. Life: Standard
❑ Vol, LTD:
❑
❑
❑
Vol. AWD: Standard
❑
❑
B
0
❑ Vol. STO:
❑
❑
❑
❑
❑ Vol. Site. Life:
❑
❑ I
❑
❑
❑ Other:
❑
❑
❑
❑
❑ Vol. Sp. AD&D:
❑
❑
❑
❑
❑ Other;
❑
❑
❑
❑
❑ Vol. Dep. Life:
❑
❑
❑
❑
I ❑ Dual;
❑
❑
❑
❑
❑ Vol, Delp, AD&D:
❑
❑
—117
❑
❑ Other:
❑
❑
❑
❑
❑ Vol. Dental: I
❑
❑
❑ Other:
C3
❑
❑
❑
❑ Vol. Vision:
❑
❑ Other:
❑
❑
❑
❑
C. Please Indicate complete carrier sales contact Information for each carrier noted above.
Pfan%eui Stuart Craft 425-91MI73 Ext.
Carrier Sales Contact Phone E-coal
StarLdwd Made Ine Hicks 425-28311
Carrier Sales Contact Phone E-mail
VSP Gabe Garcia HU52 7600 Ext. WE
Camor Sales Contact Phone E-mall
Exi.
Carrier sees Convert Phore E real
Ext.
Career Sales Conial Piero E-mal
D. CONSOLIDATED INVOICING ADDITIONAL ITEMS NEEDED: Provided below is a list of additional items that BCC will need In order to continue the
process. These items are needed, but are not required at the time of the submission of this Notification Form,
implementation
• Carder Sold Proposal(s)
• Any Existing Sell-FundedIFSA Plan Documents
• Group Application(s)
Employee Premium Contributions
Carver Plan Documenl(s)/Contract(s) • Payroll Calendar
If any carrier required a binder check, please attach a copy of each check per carrier.
Benefit Coordinators Corporation (BCC) I Two Robinson Plaza, Suite 200, Pttsburgh PA 15205 1 412.276.1111 I www.benXcef.com Page 2