TABLE OF CONTENTS
SCI~DULE OF EXCESS LOSS COVERAGE
DEFINITIONS
EFFECTIVE DATE OF COVERAGE
PREMIUM AND FACTORS PROVISIONS _
REIMBURSEMENT PROVISIONS
TERMINATION PROVISIONS
REINSTATEMENT PROVISIONS
SUBSEQUENT POLICY PERIOD PROVISIONS
GENERAL PROVISIONS
GENERAL EXCLUSIONS PROVISION
SPECIHIC EXPEDITED REIIvIBURSENIENT ENDORSEMENT
CONT-L -
DEFINITIONS
ACTIVELY AT WORK moans the performance of all the rcgu[ar duties of cmploycttient by the Covered Employee for
1G(LI010712 -Kerr
the Insured on a full-time basis (as specified in the Plan Document), at normal pay at the Covered Employees normal
place of business. An employee will be considered Actively at Work on each day of a regular paid vacation or a regular
non-working day on which he or she is not disabled, if he or she was Actively at Work on his or her last scheduled work
day.
AGGREGATE PERCENTAGE REIMBURSABLE is set forth in the Schedule of Excess Loss Coverage
ANNUAL AGGREGATE DEDUCTIBLE for any one Policy Period means the greater of_ (a) sum of the Monthly
Aggregate Deductibles; or (b) the Minimum Annual Aggregate Deductible.
BENEFIT PERIOD means the period of time specified in the Schedule of Excess Loss Coverage 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 tat alter the Effective Date, Policy Period, or waive this Policy's eligibility requirements.
COVERED EMPLOYEE means an employee of the Insured who is eligible for coverage under the Plan, and is
otherwise eligible for benefits under the Plan and covered under the Plan.
COVERED EXPENSE means medical or other expenses under the Plan to which this Policy applies, as shown in the
Schedule of Excess Loss Coverage, and which are not specifica[[y excluded by the terms of this Policy. Covered
Expense does not include any payment for the cost of administrating the Plan orother-Insured contracted services.
This Policy will reimburse, as a Covered Expettse, the patient services tax as imposed by the New Yock Care Reform
Act of 1996 (HCRA) or the surcharge imposed by the Massachusetts Uncompensated Care Pool. Any other tax or
surcharge levied by any state or other governmetttal subdivision wiil not be considered a Covered Expense under this
Policy.
COVERED PERSON means (a) a Covered Employee, (b) a dependent of a Covered Employee which dependent is
eligible for coverage under the Plan, and.is otherwise e[igible for benefits under the Plan and covered under the Plan,
or (c) if.requested in the application, a covered retired employee as defined by the Plan Document; however, unless
the Actively aCWork/Disabifity requirement is waived as shown on the Schedule of Excess Loss Coverage, a
_.. -:
--
Cov'ered Perstin7does not'includei-- ~ ~ - __ ;_°_ - - - -- •- -,..
(I) any Covered Employee who is not Actively at Work either on the Effective Date or the effective date'of his -- -
or her coverage under the Pian, whichever is later, or eligible dependents of such Covered Employee, until
the Covered Employee returns fo Actively at Work status; or
(2) any dependent of a Covered Employee if such dependent is, on the Effective Date or the-effective. date of
his or her coverage under the Plan, whichever is later, either hospital~onfined or unable to perform the
normal activities of a person of like sex-and age in good health, until the end of such confinement or
disability.
Waiver of the Actively at Work/Disability requirement does not affect rho obligation of the Insured and the Third
Party Administrator to disclose information requested by the Company for underwriting purposes and does not affect
the Company's rights in event of failure to disclose such information.
COVERED UNIT means the following: (a) an employee oovcrod as one individual under the Plan; (b) an employee
and dependents covered under the Plan; or (c) such other defined unit or units as agreed upon between the Company and
Insured. The types of Covered Units and the factors and premium rates for each type are shown in the Schedule of
Excess Loss Coverage.
EFFECTIVE DATE is the date set forth in the Schedule of Excess Loss Coverage.
EMPLOYEE BENEFIT PLAN (Also known as the PLAN) means the self-funded health care plan established by the
plan sponsor to provide certain benefits to Covered Persons.
INCURRED means with respell to medical. services or supplies, the date on which the services are rendered or supplies
arc purchased by the Covered Person; and, with respect to disability income benefits if selected in the Schedule of
Excess Loss Coverage, the date each periodic bcttcfit payment booomcs payable to the Covered Person (not the date the
disability commences). -
DEF- L
INSURED means the entity requesting Excess-Loss Insurance
LOSS, LOSSES means amounts actually Paid by the Plan for Covered Expenses.
MLI01071Z -Kerr
LOSS LIMIT PER COVERED PERSON is set forth in the Schedule of Excess Loss Coverage. However, if claims
are Paid under the Plan for a Covered Person for benefits that are covered under Aggregate Excess Loss Insurance, but
not covered under Spocific Excess Loss Insurance, the Loss Limit for that Covered Person will be increased by the
amount of such Payment.
MAXIMUM AGGREGATE BENEFIT is set forth in the Schedule of Excess Loss Coverage.
LIFETIME MAXIMUM SPECIFIC BENEFIT is set forth in the Schedule of Excess Loss Coverage.
MINIMUM ANNUAL AGGREGATE DEDUCTIBLE is set forth in the Schedule o[Excess Loss Coverage.
MONTHLY AGGREGATE DEDUCTIBLE means, with respect to a particular month, the total number of Covered
Units for that given Policy month multiplied by the corresponding Monthly Aggregate Factors as specified in thy.
Schedule of Excess Loss Coverage. However, in the event of a reduction in the number of Covered Units under the -
Plan, the Monthly Aggregate Deductible cannot be reduced to less than one twelfth of the Minimum Annuai Aggregate
Deductible. - -~
MONTHLY AGGREGATE FACTORS are set forth in the Schedule of Excess Loss Coverage.
PAY, PAID, PAYMENT means checks or drafts issued and deposited in the U.S. Mail or otherwise delivered to-the
payee, with sufficient funds on deposit to honor all outstanding drafts and checks. -
PLAIN DOCUMENT means the written document approved by the plan sponsor which describes the Plan. A copy of
the Plan Document in effect on the Effective Datc is attached to the application for Excess Loss Insurance and made a
part of this Policy.
---
POLICY PERIOD means the specified, period in the Schedule of Excess Loss toverage,.however'beginning rio earlier ' -
--.
_. - -~=- -
'than the Effective Date of this Policy and continuing until coverage terminates in accordance with the Termination -
Provisions. _ -`
SPECIFIC DEDUCTIBLEas-set forth in the.SChcdule of Excess Loss Covecag~ The Spxific-]deductible will.apply.-
separately to each Benefit Period. ~ - - - - ` -_ - .
SPECIFIC PERCENTAGE REIl4iBURSABLE is set forth in the Schedule of Excess Loss Coverage.
TIiIRD PARTY ADMINISTRATOR means a fum or person who has been retained by the Insured to Pay claims
and/or provide administrative services on behalf of the Insurod/Plan.
DEF-2
MLI010712 -Kerr
EFFECTIVE DATE OF COVERAGE
Coverage under this Policy is not effective until (a) payment of the first (lst) premium; (b) receipt of a signed
Application for Excess Loss Insurance; and (c) receipt, examination and acceptance by the Company of the Plan
Document and all other information which is material to underwriting or premium rating, whether or not specifically
requested. .
PREM[UMS 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 (1~) day of each month. Premiums are not considered paid until the premium payment is
received by the Company.
Premiums or other payments made by the Insured to their Third Party Administrator or Agent or Broker shall not be
deemed or considered payments to the Company until actually received by the Company.
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. Coverage will automatically terminate as of the end of the day on the due date of
any premium which remains unpaid at the end of the Grad Period. i
PREMIUM AMOUNT The premiums will be calculated using rates determined by the Company as set foNt in the
Schedule of Excess Loss Coverage. The amount of total premium due each.month is the sum obtained by multiplying the
applicable premium rates shown in the Schedule of Excess Loss Coverage by the actual number of appropriate Covered
Units. -
The.tnsured viii be liable for any.premium taxes.assesscd at any time against the Company beyond any taxeswlicli may -
. _ _
be payable on the premium receivedby3he 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 applicab]e Policy Period:
...
..-
The Company will not refund any portion ofthe premiums paid ifthis Policy terminates during the Policy Period.
SET OFF The Company shall be entitled to set off against reimbursements due the Insured under this Policy 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 AND AGGREGATE DEDUCTIBLE FACTOR CHANGE The Company may change the
Insured's premium rates or factors as of 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 Insured adds or deletes subsidiary or affiliated companies or divisions;
d) the date the number of Coveted Units on any premium due date vanes more than fifteen percent (15%) from
the number of Covered Units on the Effective Date; or
e) the date the Insured changes its Third Party Administrator.
The Company reserves the right to recalculate the premium rates and the Monthly Aggregate Factors retroactively for
- - __
the Policy Period, if there is more than a ten percent (10%) variance bttwCU~: _ . .; _
a) the average monthly Paid claim cost per Covered Employee under-the Plan for-the_lasttwo {2) months of the
prior Policy Period; and
b)the average monthly Paid claim cost per Covered Emp[oyoe under the Pian for the first ten (10) months of the
prior Policy Period. ~ -
PREFAC-1
I12LI010712 -Kerr
REIMBURSEMENT PROVISIONS
NOTICE OF LOSS The Insured will give written notice of Losses to the Company on the Company's customary proof
of loss form, within thirty (30) days of the daft the Insured becomes aware of the existence of facts which would
reasonably suggest the possibility that expenses covered under the Plan will be Ineurrcd which are equal to or exceed
fifty percent (50%) of the Specific Deductible or x50,000, whichever is less.
PAYMENT BY PLAN
While the determination of benefits under the Plan is the sole responsibility of the Insured, 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.
The Insured will Pay all eligible claims under, the Plan within thirty (30) days from the date adequate proof of loss is
provided to the Insured. If the Insured faits to Pay a claim within the thirty (30) day time limit, that claim wilt not count
toward the satisfaction of the deductibles or be reimbursed under this Policy.
The Insured agrees to provide funds for payment of a[I eligible expenses under the Plan. If the Insured 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. - -
SPECIFIC EXCESS LOSS INSURANCE
The Schedule of Excess Loss Coverage indicates whether Specific Excess Loss Insurance is provided under ttiis Policy.
If, while this Policy is in effect, the Lasses for a Covered Person for the applicable Benefit Period-eitceeti the Speciftc
Deductible, the Company will reimburse the Insured, subject to the tams and conditions of this Policy including the
limits set forth in the Schedule of Excess LASS Coverage, within thirty (30) days after: ~ -
(a} the Company's acceptance of the proof of loss as a satisfactory proof;
(b) the Company's receipt of proof of Payment of the benefits by the Insured-under the P-an to, or on behalf of,
the Covered Persons; and-
(c) completionAf an-audit of tlicclaim, if requested-by-either-the.Insured or-the Company; which payment by
the Insured is expressly agreed to be a condition precedent to payment: -
The amount of the reimbursement will be equal to the Specific Percentage Reimbursable times the amount by which
Losses-exceed the Specific Deductible amount, but will not exceed the Iafetime Maximum Specific Benefit. For
purposes of determining whether sucf- Lifetime Maximum Specific Benefit has been exceeded, I:osses Inctured or
Paid in any other period of excess loss coverage are included.
Losses for any Covered Person during the Policy Period will be determirtod according to the Benefit Period described in
the Schedule of Excess Loss Coverage. The Specific Deductible applies separately to each Covered Person during a
Benefit Period.
If Specific Excess Loss Insurance terminates before the end of the Policy Period, the Specific Deductible will not be
reduced.
AGGREGATE EXCESS LOSS INSURANCE
The Schedule of Excess Loss Coverage indicates whether Aggregate Excess Loss Insurance is provided under this
Policy. If the Losses for the applicable Benefit Period subject to the Loss Limit Per Covered Person, exceed-the Annuat . .
Aggregate Deductible for the Policy Period, the Company will reimburse the Insured, subject to the terms and conditions
of this Policy including ttrc limits set forth in the Schedule of Excess LASS-Coverage, within thirty (30) days after;
(a) the Company's acceptance of proof of loss as satisfactory proof;
(b) the Company's receipt of proof of Payment of eligible expenses under the Plan; and
(c) completion by the Company of asatisfactory on-site audit of the claims, eligibility and al[ records relevant to
a claim under Aggregate Excess Loss Insurance, if the Company elects to do so.
The amount of the reimbursement wilt be equal to the Aggregate Percentage Reimbursable times the amount by which
Losses exceed the Annual Aggregate Deductible amount, but will not exceed the Maximum Aggregate Benefit. The
Annual Aggregate Deductible for any one Policy Period means the greater of: (a) the sum of the Monthly Aggregate
Deductibles; or (b) the Minimum Annual Aggregate Deductible.
REIM- I
MLI410712 -Kerr
For purposes of determining amounts payable under this Aggregate Excess Loss Insurance, Losses pertaining to each
Covered Person during the Benefit Period will be limited to the Loss Limit Per Covered Person. Losses will not include
any amounts reimbursed by the Company under any other provision of this Policy. Any Loss that is Incurred at a time
when the person to whom the Loss relates is not a Covered Person will not be eligible for Aggregate Excess Loss
Insurance and will not be considered for the purpose of satisfying the Annual Aggregate Deductible.
However, if coverage terminates before the end of the Policy Period, the Annual Aggregate Deductible will be
deemed not satisfied and the Company will not be liable for reimbursement of any benefits under this Aggregate
Excess Loss Insurance.
t
REIM-2
MLI010712 -Kerr
TERMINATION PROVISIONS
This Policy and coverage provided herwnder 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 Insured that this Policy
is to be terminated;
c) the date of termination of the Plan;
d) the date the Insured suspends active business operations or dissolves; or
e) the end of the Policy Period.
This Policy may also be terminated, at the Company's option on the earliest of:
a) the last day of the third (3"') 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 Insured fails to comply with the terms of this Policy.
The Company will not refund any portion of the premiums paid if this Policy is terminated during the Policy Period.
REINSTATEMENT PROVISIONS
If this Policy terminates for any of the reasons set forth above, the Company may, at its option, approve the Insured's
request to reinstate this Policy. The Insured shall submit to the Company any forms and data the Company may require.
If this Policy is reinstated, the Insured shall pay to the Company the prcmiutns due from the date this Policy terminated.
SUBSEQUENT POLICY PERIOD PROVISIONS
At the end of a Policy Period, a subsequent Policy Period may be agreed upon in writing by. the Company and-the - - -
Insured. The terms and conditions for a subsequent Policy Period will be evidenced by the issuance of a new Schedule
of Excess Loss Coverage by the Company which shows the new premium rates Benefit Period and othernew terms.
This Policy is not automatically renewable, _ -
TERM-1
MLI410712 -Kerr
GENERAL PROVISIONS
ARBITRATION Any dispute arising out of or relating to this Policy, or the breach thueof, shall be settled by
Arbitration in accordance with the rules of the American Arbitration Association, and judgement upon the award
rendered by the arbitrators may be entered in any court having jurisdiction. The arbitrators tray not award any punitive
or exemplary damages. This provision will survive the termination or expiration of this Policy.
ASSIGNMENT Reimbursement under this Policy may not be assigned by the Insured, 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 Insured and Third
Party 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 Insured 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 rtimbursement will be made
according to the amended Plan, once the notice is received and accxpted.
i
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 Third Party Admintstrator has the
authority to alter this Policy or to waive any of its provisions.
_.
CLERICAL ERROR Clerics[ errors, whether by the Insured or by the. Company, _id_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 Insured; the"'ft~ird Party=Administrator or
any agent of the Insured: (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. - _ _ _, . _ _ -
CONCEALMENT, FRAUD This entire Policy will be void (a) if, before or after a claim or Loss, the Insured, the
Third Party Administrator or any agent of the Insured has concealed or misrepresented any. material fact or circumstance
concerning this Policy, including any claim, or (b) in any case of fraud by the Insured, the Third Party Administrator, or
any agent of the Insured relating to this Policy.
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 roqutrema-ts of such taw.
ENTIRE CONTRACT The Entire Contract between the Company and the Insured will consist of this Policy, the
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 banlmrpt Insured 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 Insured or the
Insured's Third Party Administrator will not impose upon-the Company any liability~ther than-thc.liability defined in
this Policy. In particular, the insolvency of the Insured will not make the Company liable to the creditors of the Insured,
including Covered Persons under the Plan.
INSURED REQUIREMENTS The Insured will submit by the twentieth (20th) day of each .month alt proofs, reports,
and supporting documents required by the Company. including, but not limited to, a monthly summary of a1C eligible
claims Payments processed by the Insured and number of each type of Covered Units under the Plan during the prior
month. The Insured will be responsible for the investigation, auditing, calculating and the Payment of all claims under
the Plan.
G1rN-1 - -
LEGAL ACTION The Insured cannot file suit until ninety (90) days aftex the date on which proof.of-loss is givcn_to _ -- _
MLI010712 -Kerr
the Company. The Insured cannot file suit more than three (3) years after the date on which the Insured must glut the
Company proof of claim. The three (3) year limitation is extended, if Necessary. to agree with the period allowed by the
laws of the state of issue.
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 Insured, subject to the
terms and conditions of this Policy. Nothing in this Policy shall be construed to permit a Covered Person to have a direct
right of action against the Company. The Company will not be considered a party to the Plan of the Insured, or to any
supplement or amendment to it.
MISSTATED DATA The Company has relied upon the underwriting information provided by the Insured, the Third
Party Administrator or any agent of the Insured, in the issuance of this Policy. Should information in ezisience prior to
issuance of this Policy subsequently become known which would have affected the rates, deductibles, terms or
conditions for coverage, the Company will have the right to revise the rates, deductibles, terms or wnditions as of the
Effective Date of issuance, by providing written notice to the Insured.
NOTICE FROM THE COMPANY TO THE INSURED For the purpose of any notice required from the Company
under the provisions of this Policy, notice to the Insurcd's Third Party Administrator shalt be considered notice to the
Insured and notice to the Insured shall be considered notice to the Insrrred's Third Party Administrator.
OTHER COVERAGE The reimbursement provided by this Policy is in excess of other coverage such. as group
insurance, excess instuattec, insurance, plan benefiu, including insurance or plan benefits established by any federal,
state, or local law. ~ .
PARTIES TO THE POLICY The parties to this Policy are the Insured and the Company. The Company's sole
liability under this Policy is to the Insured. 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 Insured and the Third Party Administrator.
RECORDS The Insured 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 Insured will melee aII such records available. to the
Company as needed to evaluate its liability under this Policy.
The Instued 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, voidable, invalid, or otherwise unenforceable, whether or not
such a provision is contrary to public policy, will not render any of the tr,[naining provisions of this Policy invalid.
TERMINATION OF THE INSURED'S PLAN The Insured will immediately notify the Company, if the Plan is
terminated.
THIRD PARTY ADMINISTRATOR The Insured may retain a Third Patty Administrator to act as an agent for the
Insured in performing any or all of the duties as designated by the Insured. Without waiving any of its rights under this
Policy, and without making the designated Third Party Administrator a party to this Policy, the Company agrees to
recognize the Third Party Administrator as an agent of the Insured. The Insured will immediately notify the Company in
writing if the agreement between the Insured and the Third Party Administrator terminates.
THIRD PARTY RECOVERY The Plan shalt undertake to pursue any and all valid claims that the Plan may have
against third parties arising out of any occurrence resulting in a payment by the Pian or the Company, and to account
for and pay to the Company any amounts recovered which were previously reimbursed by the Company to the
Insured under this Policy, regardless of whether this Policy is still in force on the date of recovery. Third partysltall
mean another person, entity, or insurance company. Additionally. the Insured or Plan administrator shall GEN-2
natify the Company immediately upon discovering that a
claim against a third party may exist. Should the Insured fail to pursue any valid claims against a third party and-the
Company becomes liable to reimburse the Plan, then the Company shall have the right to exercise artd enforce all of
the Insured and/or Plan's rights against such third party.
Company shall also be assigned all rights of recovery if a payment is made for which the Plan is or becomes entitled
MLI010712 -Kerr
to receive payment from a third party.
If the Payment received from a third party is less than the total amount paid by the Plan on behalf of the Covered
Person, the Company is entitled to recover first, in full, any amount paid by the Company under this Policy as well as
any expenses of collection incurred by the Company. AI[ remaining amounts shall be paid to the Insured.
t
GF.N-3
MLI010712 -Kerr
GENERAL EXCLUSIONS PROVISIONS
'The Company will not reimburse the Insured for any of the fallowing:
(a) Any paytncnt which does not strictly comply with the terms and conditions of the Plan Docutttent;
(b) Any payment or expense caused by or resulting from war, declared or undeclared, invasion, acts of
foreign enemies, hostilities, civil war, rebellion, insurrection, military or usurped power, or martial law or
confiscation by order of any government or public authority;
(c) Any payment for litigation costs and expenses, extra-contractual damages, compensatory ,damages,
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 Insured, Plan, Third
Party Administrator or any agent or representative of the Insured, Plan or Third Party Administrator;
(d) Any payment or expense for accident or illness arising out of activities performed for profit, including _
seIf-employment; ~ ,
(e} Any payment for occupational accidents or illnesses which are also eligible expenses covered. by Workers' ''
Compensation or Occupational Disease law, or similar legislation, whether or ttot coverage under such'law is '
actually in force;
(f) Any payment which is recoverable under the Plan Documents Coordination of Benefits provision; -
(g) Any amount paid which is in excess of the Plan's benefits disclosed, in writing, to the Company; -
(h) Expenses in eonttection with surgery or treatment classified by the Centers for Medicare and Medicaid ~ -
Services of the United States Department of Health and Human Services as "experimental" oc
"investigational";
(i) Any payment under the Plan on account of a benefit which is not shown on the Schedule of Excess Loss
Coverage as a Plan benefit for which coverage is provided undo this Policy; or _ _.
(j) Any payment under the Plan not reported to the Company within six (6) months after the end of the Benefit
Period. .
EXCIr 1
MLI010712 -Kerr
Specific Expedited Reimbursement Endorsement
This Endorsement forms part of the Excess Loss Insurance Policy to which it is attached.
Insured: Kerr
Policy Number: MLI010712 Effective Date: January 1, 2004
SPECIFIC EXPEDITED REIMBURSEMENT OPTION
An additional provision is hereby added to the terms and conditions for Specific Excess Loss Insurance in
the Policy as follows:
SPECIFIC EXPEDITED REIMBURSEMENT Without waiving any rights under the Excess
Loss Insurance Policy, the Company hueby establishes Specific Expedited Reimbursement. The
additional toms and conditions undo which Expedited Reimbttrsement will be provided for
Specific Excess Loss claims are as follows:
(A) The claim must be fully processed by the Third Party Administrator and must be ready for
payment undo the Employce Benefit Plan within the Benefit Period during which the claim
was Incurred; and '
(B) The Insured must have Paid-under the Employee Benef t Ptan, the Specific Deductible for the
Covered Person to whom the claim relates, plus, in addition. to the Specific Deductible
Amount, aYleast.{:$1,000];-and
(C) The claim, and supporting documentation satisfactory to the Company, must be received by
the Company no late than (flue (5) days prior toJ the end oftheBeneftt-Period during which
the claim was Incurred and processed; and
(D) { (The claim must be for more than $1,000.] }
If the foregoing requirements are satisfied, the Company will promptly send to the Insured
reimbursement for the amount that is eligible for reimbursement undo Specific Excess Loss
Insurance. Upon receipt of the Expedited Reimbursement, the Insured must pay the Employee
Benefit Plan's payment within [five (5)] days. The Company's reimbursement may not be
deposited until the Employce Benefit Plan's payment has been paid. If the Insured does not pay
the Employee Benefit Plan's payment within the [five (5)] day period, the reimbursement must be
refunded to the Company.
If any portion of the Company's reimbursement is not used to pay the applicable benefits undo
the Employee Benefit Plan, due to discounting or any other reason, such portion must be returned
to the Company within [five (5) working] days after it is received by the Insured by refund, credit,
or otherwise.
If the Insured fails to comply with ail of the above conditions, the right to receive Specific
Expedited Reimbursement shall be rescinded.
Except as specifically set forth huein, all terms and conditions of the Excess Loss Insurance Policy shall
remain in full force and effect.
MLSPEX- I
Policy No. MLI0107I2 -Kerr
This Endorsement is intended solely to provide an optional expedited method of reimbursement between
the Company and the Insured, and shall not affect the Employee Benefit Plan or the Insured's obligations
under the Employee Benefit Plan in any way, and this Endorsement shall not create any rights in favor of
any third party.
Al! terms and conditions, other than as stated above, remain unchanged.
Executed at our Home Office.
Monumental Life Insurance Company
~~
Secretary President
MLSPEX-1
Policy No. MLI010712 -Kerr
MONUMENTAL LIFE INSURANCE COMPANY'
Administrative Office: 132b S. Ridgewood Avc, Suite L 1, Daytona Beach, FL 32114
Phone: 1-888-500-EBUI(3284)
SCHEDULE OF EXCESS LOSS COVERAGE
This Schedule of Excess Loss Coverage is only applicable to Excess Loss Insurance provided by the Company
during the Policy Period shown below.
Insured: Kerr, County of
Policy Number: MLI010712
Effective Date: .Tanuary 1, 2004
Coverage specified herein is applicable only during the Policy Period from January 1, 2044 to January 1, 2005,
and is further subject to all terms and conditions of this Policy.
Actively at WorldDisability requirement. ^Applied ®Waived with Approved Disclosure
The Actively at Work/Disability requirement. is explained. in the definition of "Covered Person' in the Definitions
Section.
SPECIFIC EXCESS LOSS INSURANCE ®Yes ^ No
.Tr,-.
Benefit Period: Covered Expenses Incurred from ~anuary 1, 2004 through December 31, 2004 and Paid from
,Lanuarv 1, 2004 through December 31. 2004; however, if the Policy is terminated before the end of the originally
scheduled Policy Period set forth above, Covered Expenses must be Incurred from January, 1, 2004 through the
termination date and Paid from January 1.2004 through the termination date to be eligible for reimbursement.
Specific Deductible ® Per Covered Person ^ Per family $40,000
t
Aggregating Specific Deductible IV/A
Specific Percentage Reimbursable 100 96
Lifetime Maximum Specific Benefit Per Covered Person (including Specific Deductible):
^ $500,000 ®$1,000,000 ^ $2,000,000 ^ Other $N/A
Covered Expenses under Specific Excess Loss: ~ ~ -
®Medical ®Stand AIone Prescription Drug Program
Common Accident Provision Yes ^ No®
Common Accident means if morathan one-Covered Person in the same immediate family-incurs Covered Expenses as
a result of the same accident, the Specific Deductible will be applied only once to all Covered Expenses Paid because
of that accident for alt Covered Persons in the family during the same Benefit Period.
Covered Expenses Incurred from N/A through N/A will be limited to $ N/A per QCovered Person OFamily
Spec Premium Rates Per Month
Covered Units	Number of Units on Effective Date	Rates er Covered Unit
Si le	206	$ 38.47
Famil	62	$ 89.22
N/A	N/A	N/A
N/A	N/A	NIA
AGGREGATE EXCESS LOSS INSURANCE ®Yes ^ No
Benefit Period: Covered Expenses Incurred from .Tanuary 1, 2004 through December 31. 2004, and Paid from
,Lanuary 1, 2004 through December 31.2(104; however, if the Policy is terminated before the end of the originally
scheduled Policy Period set forth above, no reimbursement wilt be made under Aggregate Excess Loss Insurance.
Covered Expenses Incurred from NIA through N/A will be limited to $ NIA or N/A % of the Annual Aggregate
Deductible, whichever is greater.
Covered Expenses under Aggregate Excess Loss Coverage:
® Medical ®Stard Alone Prescription Drug Program
^ Dental Care ^ Weekly (Disability) Income
^ Vision Care ^ Other N/A
Aggregate Percentage Reimbursable 100 96
Maximum Aggregate Benefit: ^ 5500,000 ®$1,000,000 ^ Othu $ N/A
SCI~D-1
MLI010712 -Kerr
Minimum Annual Aggregate Deductible: $1,226,SG4 or 100 ~ of the first Monthly Aggregate Deductible amount
times 12, whichever is greater.
Loss Limit Per Covered Person: $ 40,000
Monthly Aggregate Rectors
Covered Units	# on Effective Date	Medical	Prescription Drug	Dental
Single	206	$27735	Included	N/A
Family	62	$727.09	Included	NIA
MIA	NIA	N/A	N/A	NIA
N/A	N/A	NIA	N/A	NIA
Aggregate Excess Loss Premium ®per Covered Unit per month Qannua( $5.73 perm.
SPECIAL CONDITIONS:
ENDORSEMENTS ATTACHED TO AND MADE PART OF POLICY AT EFFECTIVE DATE:
- - PREMIUM
(a)	SPECIFIC EXPEDITED REIIviBURSEMENT ENDORSEMENT	®YES ^NO	Included
(b)	SPECIFIC TERMINAL LIABLITY ENDORSEMENT	^YES ~NO	N/A
(c)	AGGREGATE ACCOMODATION ENDORSEMENT	^YES ®NO	N/A
(d)	AGGREGATE TERMINAL LIABILITY ENDORSEMENT	^YES ~NO	NIA
(e)	AGGREGATING SPECIFIC DEDUCTIBLE ENDORSEMENT	_
^YES ®NO	N/A
(t)	OTHER N/A	^YES LINO	N/A .
~"( r
ACCEPTED BY TI-IE INSURED TIES ~ DAY OF ~ , 20 y
--z ....,,, ~ ~.
SCHED-2
ML[010712 -Kerr