Mutua! of Omaha Insurance Company Connie Potter
United of Omaha Life Insurance Company Sr. Account Assistant
17300 Henderson Pass Suite 220 San Antonio Group Office
San Antonio, Texas 78232
t (210) 403-2794 or 888-929.4464 f (210) 494-5765
connie.potter@mutualofomaha.com
May 9, 2005
Judge Pat Tinley
Kerr County
700 Main Street
Kerrville, TX 78028
RE: Life/AD&D -Policy # GLUG 487A
Dear Judge Tinley,
~ ~~ ~~
Murua~~Omaea
Comr~nies
Please find enclosed for your records is your Master Contract for the Group Life/ADD&D policy. In
addition, a copy of the signed Application for Stop Loss Insurance in enclosed for your records,
Please do not hesitate to contact our Account Executive, Jaime Ochoa at (888) 949-4464 x23 with any
questions you may have.
Sincerely,
~~rrni~~d1~_
Connie Potter
Group Health Account Assistant
cc: Don Wallace
1.
2.
3.
4.
APPLICATION TO ~ .~ .
MUTUAL OF OMAHA INSURANCE COMPANYIUNITED OF OMAHA LIFE INSURANCE COMPANY
.,
FOR S.T,OP LOSS INSURANCE
.,..
. ~ ~' .
UNDERWRITING COMPANY (Check Appropriate. Box~Below): ~ ~ ~ ~ ~ ~~~
^ MUTUAL OF OMAHA INSURANCE COMPANY `
~7 UNITED OF OMAHA LIFE INSURANCE COMPANY
Home Office: Mutual of Omaha Plaza, Omaha, NE 68175
. ~.
APPLICANT Full Legal Name) Kerr Count
STREET ADDRESS 700 Main Street
.. ., .
For Home Office :Use Only
. ,.
POLICY NUMBERASSIGNED
{ w~ ~
CITY ....K~r_r_tiil?.~. ~ ~, . , STATE Tx ZIP CODE -~-. H~?~ ~ .--
TELEPHONE NUMBER ~ 30 )-~~~::_ - .~.z; s~~ , ~ ~.. ........, . _ . _ ... ~ ~ .
,..
. ..
The Applicant applies for stop loss insurance with the folbwin~ terms and conditions,., ~
This section may be updated by,an addendum to this Application: The-Application consists of~~this #or~n~ and
.,
any written addendums to this Application, ~ attached to this ~ Application and signed by an officer of ~ the
underwriting company. '
:~
..._.~.
FINANCIAL CONDlT10N
Within the last five ~5) years, has the Applicant remained continually solvent? ~ Yes
Does the Applicant reasonably expect to be solvent within the next 12 months? ~I Yes
If no to either question, please give details.
Solvent means not having filed a voluntary or involun#ary petition in bankruptcy, a reorganization or an arrangement
with creditors, or a general assignment for the benefit of creditors, the ability to pay debts as they become due, not
having a trustee, receiver or other custodian appointed on its behalf, or any other case or proceeding under any
bankruptcy or solvency law, or the commencement of any dissolution or liquidation proceeding.
Requested effective date of the policy: _ January _ 1 ~ Z 0 0 5~, _~
This A lication is submitted with the followin advance a ent: $ ~ 3 '~
PP 9 P Ym
... r....., . :~~ ~;.. . .
.
1 ~634GA-EZ 03 STOP LOSS ~ ~ -. _ ~.._ .. .~ ~ .. .: :; ,~:~ , ~.. ~:.; .. .:. . ~... ,~ ... .. . .
:~~
^ No
^ No
s
~. '
W M
I understand that the underwriting company will rely and act upon the answers, statements and any misstatements or
omissions of information that are made on this Application or given and used in the preparation of the ~ProposaC upon which
#h~~ Application is based. Erroneous information end :any material omission of information may result in the rescission,
,. _
:ellation or rerating of coverage issued in reliance thereon. ~ . -
if this Application is not approved by an officer at the Home Office of the Underwriting~Company,'no coverage is in effect at.
any time and any advance payment received will be retuned. ....~ ~ _ . ~ .
. If this Application is approved by an officer at the Home~Office of the Underwriting Company,.it will be attached to and made a
part of the policy and any reissue of the policy whichf is approved by an. officer at the Home Office o f t he U ndenivritirig
Company. The effective date of the Policy is the effect'rv~ date shown on the.attached addendum, which is made a part of this :.
Application. ~ ~. ~ ~ ' - .. ~.. , ; . ..
Receipt of the policy or any reissued-policy, and payment of any subsequen# premium for the policy or any reissued policy, will
constitute the applicant's acceptance of the provisions of the policy or the reissued poNcy.~ ~ ~ ~ ~ - a - ~ ~ ~:
.. .
I represent that no employee contributions or plan assets shall be used to pay premium or othen~ise fund stop loss.coverage.
Stop loss reimbursements shall not be used to fund plan benefits nor shall this stop loss insu~anc~ be considered an asset to
my plan. ~ .~ .: , . .. . ; -. .
Deposit of premium by the UndenNriting Company does=.not constitute ari~approval or acceptance of liability if issuance ~~f die
policy is not approved by the Underwriting Company. Ifissuance of the policy is not,approved, the ~rer~ic~m; will be refunded
regardless of whether or not it was deposited, . ~ ~~ ~ ~ ~~ - ~ ~ ~ -. ' ~' ` .'
For Applicant:
r
Accepted By
.e
-.. .. -
i
r
~a. .z>. .:.~
• _ _
10634GA-EZ 03 STOP LOSS ~. ~. ~ ~...., :., ~ w :. ~..:. ..; ~. - .. . •... ~ -
United of Omaha Life Insurance Compang
Home Office: Mutual of Omaha Plaza, Omaha, Nebraska 68175
A Stock Company (herein called the Company)
has issued this Policy to Kerr County (herein called Policyholder)
This Policy is issued in consideration of:
(a) the terms, conditions and limitations of this Policy; and
(b} the application for this Policy, a copy of which is attached.
This Policy is effective January 1, 2005, at 12:01 a.m., Standard Time, at the main office of the
Policyholder.
The Company agrees to pay the Insured Persons the benefits to which they are entitled, subject to the
terms, conditions and limitations of this Policy.
The Certificate of Insurance, Form 7000CI-U-EZ No. 5, is made a part of this Policy.
This Policy is issued in and is subject to Texas law.
THIS IS NOT A POLICY OF WORKERS' COMPENSATION INSURANCE. THE EMPLOYER DOES NQT
BECOME A SUBSCRIBER TO THE WORKERS' COMPENSATION SYSTEM BY PURCHASING THIS
POLICY, AND IF THE EMPLOYER IS A NONSUBSCRIBER, THE EMPLOYER LOSES THOSE BENEFITS
WHICH WOULD OTHERWISE ACCRUE UNDER THE WORKERS' COMPENSATION LAWS. THE
EMPLOYER MUST COMPLY WITH THE WORKERS' COMPENSATION LAW AS IT PERTAINS TO
NONSUBSCRIBERS AND THE REQUIRED NOTIFICATIONS THAT MUST BE FILED AND POSTED.
UNITED OF OMAHA LIFE INSURANCE COMPANY
/.
Chairman and CEO
~r~
e
Murua~~OmaHa
GROUP POLICY NO. GLUG487A
(herein called Policy)
Secretary
(*)
7004GM-U-EZ 2001
GENERAL PROVISIONS
Capitalized terms not defined in these GENERAL PROVISIONS are defined in the Certificate or any
other document made a part of this Policy.
1. CHANGE IN PREMIUM RATES
The Company has issued this Policy based upon current information regarding:
(a) the industry of the Policyholder and the age, gender, occupation, earnings, location, and size of
the Policyholder's employee population; and
(b) laws, regulations and judicial and administrative orders and decisions affecting benefits and the
cost of administration.
Accordingly, the Company reserves the right to change premium rates on or after the date there is a
change in any of the factors described in (a) or (b) above resulting from or relating to:
(1) an increase in premium tax, guarantee or uninsured fund assessment, or other governmental
charge based upon or related to premium;
(2) a merger or consolidation, or an acquisition or divestiture (through stock, assets or exchange)
of all or part of a business enterprise affecting the Policyholder's employee population; or
(3) the enactment, issuance, amendment, or enforcement of any law, regulation, judicial or
administrative order or decision.
in addition to the right to change premium rates in accordance with the preceding paragraphs, the
Company may change premium rates:
(a) any time after the most recent Rate Guarantee Date shown in this Policy, provided the Company
has given at least 60 days advance written notice of the premium rate increase;
(b) on or after the date there is a change in benefits or eligibility for benefits under the Policy; or
(c) on or after the date there is an increase or a decrease of 10% or more in the number of employees
insured under the Policy.
2. PAYMENT OF PREMIUMS
The first premium Due Date is the effective date of this Policy for the Period of Coverage beginning
on that date and ending on the last day of the same month. Premiums for each subsequent Period of
Coverage are due by the corresponding Due Date:
Period of Covera,~e, Due Date
January 1 through January 31 January 1
February 1 through February 28 or 29 February 1
March 1 through March 31 March 1
.. .... ,. O t~ri~ ~
October 1 through October 31 October 1
November 1 through November 30 November 1
December 1 through December 31 December 1
The premium payable for each Period of Coverage is the sum of the individual premiums for each
Insured Person. Individual premiums are based on an Insured Person's classification when a Period
of Coverage begins.
October 1 through October 31
November 1 through November 30
December 1 through December 31
October 1
November 1
December 1
The premium payable for each Period of Coverage is the sum of the individual premiums for each
Insured Person. Individual premiums are based on an Insured Person's classification when a Period
of Coverage begins.
Payment should be made to the Company:
(a) at a lockbox designated by the Company;
(b) at its Home Office; or
(c) at another location authorized in writing by an officer of the Company.
Premium shall be considered to be paid on the date the premium is received at the location described
in (a), (b) or (c) in the preceding paragraph.
If this Policy terminates for any reason:
(a} the Policyholder is liable for all premiums to the date of termination, including premiums for any
grace period or part of any grace period; and
(b} all unpaid premiums are due no later than the date of termination.
3. GRACE PERIOD
n
Premium is due and payable on or before the Due Date shown in the GENERAL PROVISION 2.
herein ~~(PAYMENT OF PREMIUMS). After the first premium has been paid, a grace period of 31
days from each Due Date shall be granted for payment of premium. If the Policyholder does not pay
the premium by the end of the grace period, this Policy shall automatically terminate at the end of
the grace period in accordance with GENERAL PROVISION 4. herein (POLICY TERMINATION
BY THE POLICYHOLDER). This Policy will remain in force during the grace period; except, if
the Policyholder has given advance written notice to the Company that this Policy will terminate
prior to the end of the grace period, this Policy will remain in force only until the termination date.
4. POLICY TERMINATION BY THE POLICYHOLDER
This Policy shall be considered terminated by the Policyholder on the earliest of:
(a) the end of the grace period, if all due premium is not paid by then;
(b) the day chosen by the Policyholder, if advance written notice is given to the Company; or
(c) the day a premium increase is effective but has not been accepted in writing by the Policyholder.
5. PULICY TERMINATION BY THE COMPANY
Following at least 31 days advance written notice to the Policyholder, the Company has the right:
(a) to terminate this Policy if the number of employees insured is less than 10 or less than 100% of
those eligible for insurance;
(b) to terminate either this Policy or any dependents' insurance if the number of employees with
dependents insured is less than (Not Applicable) of those employees who have eligible
dependents; or
(c) to terminate this Policy any time after the most recent Rate Guarantee Date shown in this Policy,
unless this termination right is inconsistent with any Termination Rider which is made a part of
th1S Pollcy.
6. REINSTATEMENT AFTER TERMINATION OF THIS POLICY
If this Policy terminates for any reason, it may be reinstated at the Company's sole discretion. The
Company may choose not to reinstate the Policy. The Policy may be reinstated only if:
(a) an officer of the Company agrees in writing to reinstate the Policy;
(b) the Policyholder agrees in writing to accept any written conditions of reinstatement imposed by
the Company; and
(c) the Policyholder pays the Company all premiums then due and unpaid, including any premium
for the time insurance was in effect during the grace period.
7. INDIVIDUAL CERTIFICATE
The Company will issue the Policyholder individual Certificates for delivery to Insured Persons.
The Certificate describes insurance coverage under the Policy and any conversion rights available
upon termination of coverage.
8. MISSTATEMENT OF AGE
If the age of an Insured Person has been misstated, the Company will make an adjustment either:
(a) in premiums; or
(b) in the amount of insurance, if the amount of insurance depends on age. If the amount of
insurance is increased, the Company must first receive all additional premiums.
9. INCONTESTABLE CLAUSE
The Company will not contest the validity of this Policy after it has been in force one year, except
for nonpayment of premium.
10. INFORMATION TO BE FURNISHED BY THE POLICYHOLDER/PRIVACY
The Policyholder is responsible for keeping confidential insurance records. These records are to be
kept in a way which will assure the privacy of medical and other personal information. The records
must show:
(a) persons insured by classification and any persons eligible but not insured;
(b} the amount of money contributed by the Policyholder toward premiums; and
(c} any other insurance information which the Company may reasonably request.
These records and any other insurance information which the Policyholder has or reviews will be
used by the Policyholder only for the purpose of Policy administration.
The Policyholder will furnish, as the Company requires, any insurance information on the
Company's forms which are needed for insurance administration.
The Policyholder's books and records which may have a bearing on the insurance under this Policy
shall be open to the Company for inspection. The books and records may be inspected at any
reasonable time while this Policy is in force, and for one year a~erwards.
The Policyholder shall provide the Company written notice within 60 days aver any Insured
Person's eligibility for coverage under this Policy ends. If the Company does not receive such
written notice within this 60 day time period, the Policyholder shall pay to the Company a late notice
charge equal to the amount of the premium that would otherwise be payable for the coverage for
such person from the date the person's eligibility ended until 60 days prior to the date on which the
Company received written notice of ineligibility from the Policyholder.
In addition to the Policyholder's obligation to pay the late notice charge, at its sole discretion, the
Company may require the Policyholder to reimburse the Company in an amount equal to:
(a) the amount of any claims paid on behalf of the ineligible person and/or any dependents of such
person during the time the person was ineligible; less
(b) the amount of the late notice charge.
The Policyholder shall pay the late notice charge and/or reimburse the Company for claims in
accordance with this provision within 60 days after receipt of the Company's written request for
payment. The Company may satisfy the late notice charge by retaining an amount equal to the
charge from any premium remitted by the Policyholder to the Company on behalf of any ineligible
person. The late notice charge and any amount of claims reimbursed to the Company in accordance
with this provision shall not be considered to be premium for coverage under the Policy.
The Company's right to receive the late notice charge and reimbursement for claims in accordance
with this provision shall not preclude the Company from pursuing any other remedies available to
the Company.
In no event shall the Company provide coverage under the Policy beyond the date a person's
eligibility ended, unless coverage is continued in accordance with the terms of the Policy. If
coverage is continued in accordance with the terms of the Policy, and the applicable premium is paid
for such coverage, the late notice charge and the obligation to reimburse the Company for claims as
described herein shall not apply.
United of Omaha Life Insurance Company
If required by state law, Countersigned by:
Licensed Resident Agent
RIDER
This rider is made a part of Group Policy GLUG-487A.
This rider is effective January 1, 2005.
In the event of a conflict between this provision and any other provision of the Policy, including the
Certificate, this provision shall control. This provision shall be subject to all provisions of the Policy,
including the Certificate, not in conflict with this provision.
The following is made a part of the policy.
AUTHORITY TO INTERPRET POLICY
By purchasing the policy, the Policyholder grants United of Omaha Life Insurance Company the
discretion and the final authority to construe and interpret the policy. This means that United has the
authority to decide all questions of eligibility and all questions regarding the amount and payment of any
policy benefits within the terms of the policy as interpreted by United. In making any decision, United
may rely on the accuracy and completeness of any information furnished by the Policyholder or an
insured person. United's interpretation of the policy as to the amount of benefits and eligibility shall be
binding and conclusive on all persons.
The Policyholder, as Plan sponsor, agrees that the Policyholder retains full responsibility for the legal
and tax status of its benefits program and releases United from all responsibility for the reporting and the
employment-based design of the program and from all other responsibilities not accepted in writing by
an officer of United.
UNITED OF OMAHA LIFE INSURANCE COMPANY
~~~~'
Chairman and CEO
2024GR-EZ
ELIGIBILITY ADDENDUM
GLUG-487A
Effective Date: January 1, 2005
Insurance for persons covered under a state mandated continuation law will be in accord with that law.
PREMIUM RIDER
This rider is made a part of Group Policy GLUG-487A.
This rider is effective January 1, 2005.
The premiums for the policy will be as follows:
CLASSIFICATION S
All eligible active employees
LIFE INSURANCE PREMIUM(S~
_~
Employee ................................................................................$.20 per month for each $1,000 of insurance
HEALTH INSURANCE PREMIUM
The monthly premium for Accidental Death and Dismemberment Benefits is:
Employee ................................................................................$.02 per month for each $1,000 of insurance
RATE GUARANTEE DATE
January 1, 2007
Notwithstanding anything to the contrary in the GRACE PERIOD provision in the Policy, the
Policyholder and the Company agree as follows:
If, in addition to this Policy, the Policyholder has any other insurance policy ("Insurance Policy"}, group
health maintenance organization contract ("HMO Contract"), or Administrative Services Agreement or
other type of service agreement ("Service Agreement") with the Company or any affiliate of the
Company, and an administration fee or other payment described in a Service Agreement ("Fee") is not
paid in full by the required due date or premium is not paid in full during the grace period for this Policy
or an Insurance Policy or HMO Contract, the total amount of premium and Fees paid for this Policy and
each Insurance Policy, HMO Contract and Service Agreement during the month in which the premium
or Fee is not paid in full ("the Delinquent Month"} will be allocated to this Policy and each Insurance
Policy, HMO Contract and Service Agreement on a pro-rata basis.
The amount of premium and Fees allocated to this Policy and each Insurance Policy, HMO Contract,
and Service Agreement will be determined by multiplying (a) the amount of premium due for this Policy
and each Insurance Policy and HMO Contract during the Delinquent Month and the amount of Fees due
for each Service Agreement during the Delinquent Month by (b) the percentage equal to (i) the total
amount of premium and Fees paid for this Policy and each Insurance Policy, HMO Contract and Service
Agreement during the Delinquent Month divided by (ii) the total amount of premium and Fees due for
this Policy and each Insurance Policy, HMO Contract and Service Agreement during the Delinquent
Month.
Form 105GR-EZ
The Policyholder and the Company acknowledge and agree that the method of allocating premium and
Fees described in this provision will result in (a) the full amount of premium not being paid during the
grace period for this Policy and each Insurance Policy or HMO Contract, and (b} the full amount of Fees
not being paid by the required due date for each Service Agreement. Accordingly, notwithstanding
anything to the contrary in this Policy or any Insurance Policy, HMO Contract or Service Agreement,
the following will occur:
1. This Policy and any other Insurance Policy or HMO Contract will automatically terminate on the
date described in this Policy and such other Insurance Policy or HMO Contract for non-payment of
premium; and
2. Any Service Agreement will automatically terminate at the end of the Delinquent Month.
Dated: March 11, 2005
UNITED OF OMAHA LIFE INSURANCE COMPANY
,~1~.,,~ ~~ f
Chairman and CEO
IMPORTANT INFORMATION ABOUT COVERAGE UNDER THE TEXAS LIFE,
ACCIDENT, HEALTH AND HOSPITAL SERVICE INSURANCE GUARANTY
ASSOCIATION
Texas law established a system, administered by the Texas Life, Accident, Health and Hospital Service
Insurance Guaranty Association (the "Association"), to protect policyholders if their life or health
insurance com an fails to or cannot meet its contractual obligations. Oniy the policyholders of
p Y .. .
insurance companies which are members of the Association are eligible for this protection. However,
even if a company is a me:~ber of the Association, protection is limited and policyholders must meet
certain guidelines to qualify. (The law is found in the Texas Insurance Code, Article 21.28-D.)
BECAUSE OF STATUTORY LIIVIITATIONS
POSSIBLE THAT THE ASSOCIATION MAY
COVER YOUR POLICY IN FULL.
ON POLICYHOLDER PROTECTION, IT IS
NOT COVER YOUR POLICY OR MAY NOT
Eligibility for Protection by the Association
when an insurance company which is a member of the Association is designated as impaired by the
Texas Commissioner of Insurance, the Association provides coverage to policyholders who are:
(a) residents of Texas at the time that their insurance company is impaired; or
(b) residents of other states, ONLY if the following conditions are met:
(1) The Policyholder has a policy with a company based in Texas;
(2) The company has never held a license in the policyholder's state of residence;
(3} The policyholder's state of residence has a similar guaranty association; and
(4) The policyholder is not eligible for coverage by the guaranty association of the
policyholder's state of residence.
Limi#s of Protection by the Association
w.-w~~
For Accident, Accident and Health, or Health Insurance up to a total of $200,000 for one or more
policies for each individual covered.
For Life Insurance:
(a) net cash surrender value up to a total of $100,000 under one or more policies on any one life; or
(b) death benefits up to a total of $300,000 under one or more policies on any one life.
For Individual Annuities net cash surrender amount up to a total of $100,000 under one or more policies
owned by one contractholder.
For Group Annuities:
(a) net cash surrender amount up to $100,000 in allocated benefits under one or more policies owned
by one contractholder; or
(b} net cash surrender amount up to $5,000,000 in unallocated benefits under one contractholder
regardless of the number of contracts.
(*)
9763GI-EZ TX Rev 04 GLUG-487A
THE INSURANCE COMPANY AND ITS AGENTS ARE PROHIBITED BY LAW FROM
USING THE EXISTENCE OF THE ASSOCIATION FOR THE PURPOSE OF SALES,
SOLICITATION, OR INDUCEMENT TO PURCHASE ANY FORM OF INSURANCE.
WHEN YOU ARE SELECTING AN INSURANCE COMPANY, YOU SHOULD NOT RELY ON
COVERAGE BY THE ASSOCIATION.
Texas Life, Accident, Health and Hospital Service
Insurance Guaranty Association
6504 Bridge Point Parkway, Suite 450
Austin, Texas 78730
800-982-6362
wwvv.txlifega.org
Texas Department of Insurance
P.O. Box 149104
Austin, Texas 78714-9104
800-252-3439