Agenda - 4-7-14 Reg. Meeting - Laserfiche WebLink

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Group Name: County of Lee 22. Are you selecting the Flexible Spending Account (FSA) administered by BCBSNC for your employees? ❑Yes Q No If yes, check which element(s) of the FSA are being offered to your employees: FSA with medical? ❑ Yes ❑ No FSA dependent care? ❑ Yes ❑ No FSA limited purpose (HSA only)? IF Yes ❑ No 23. Certification of Compliance with Federal and /or State Mandates: Federal Social Security laws require employers to provide primary health care benefits under employer group health plans to certain individuals who are entitled to Medicare. The Group certifies and agrees that individuals eligible for Medicare, who are required to receive primary health care benefits under the Group's employee group health plan pursuant to federal Social Security laws, will be enrolled in a manner consistent with such laws. The Group hereby agrees to indemnify BCBSNC, hold it harmless against and reimburse it for any and all expenses paid or incurred by BCBSNC due to any act or omission of the Group or the employer inconsistent with the relevant Social Security laws, as amended. Life /ADD /STD: ❑ Renewal (No Changes) Only complete this section if you are adding or changing coverage for Life /Accidental Death & (If you check No Changes - do not Dismemberment (ADD) /Short Term Disability (STD) complete the Life /ADD /STD section.) Underwritten by USAble Life, an independent life insurance company, that does not provide BCBSNC El Renewal (With Changes) products or services and is solely responsible for the life and disability insurance coverage below. 24a. Number of Employees: 24b. Employer Contribution (percentage): Eligible: Enrolled: Life and ADD % Supplemental % Dependent Life % STD % 25. Supplemental Short Term Disability Life /ADD* ❑ Life ❑ ADD ❑ Salary Flat Class Descriptions Multiple ❑ Schedule ❑ Amount of Insurance Amount of Insurance Maximum Weekly Benefit 2. 2. 2. 2. 3. 3. 3. 3. 4. 4. 4. 4. * If Life and ADD benefit is a multiple of salary, the amount will be rounded to the next higher $1,000. 26. Short Term The maximum weekly and the benefit Disability Accident Sickness Duration Y STD benefits is $ may not exceed o /o (non - occupational): of an insured's weekly income (excluding bonuses, overtime or any Days/ Days/ Weeks form of extra a P Y)• 27. Dependent Life Insurance (Benefit amounts are limited in some states): ❑ Yes [_1 No Children: E] from birth to 6 months $ Spouse: $ ❑ 6 months to 26 years $ 28. Reductions and Termination (Benefit reduction due to age will be effective on the insured's birthday.) Employee Life and ADD benefits reduce by the following percent or to the amount shown. Benefits terminate when an employee is no longer eligible as an active employee or at retirement. At Age 65 At Age 70 Terminates Other 29. Guaranteed Issue Amount $ (Life and ADD amounts over Guaranteed Issue are subject to evidence of insurability.) COMPLIANCE NOTICE: USAble Life does not provide legal or tax advice. Based upon information you have provided USAble about your group, USAble Life will notify you if USAble Life perceives any obvious deficiency in your plan, but you must consult your own legal counsel for definitive advice and opinions regarding your plan's compliance. WARNING: It is or may be a crime to knowingly provide false, incomplete or misleading information to USAble Life for the purposes of defrauding USAble Life or other person. Penalties may include imprisonment, fines or a denial of insurance benefits in accordance with applicable state law. It is further understood and agreed that this application shall be made a part of the USAble Life policy or policies applied for and that no insurance shall be effective until approved by USAble Life's home office. PAGE 3 of 4