Delta Dental Plan Administrative Services & Financial Agreement
CITY OF DUBUQUE, IOWA
MEMORANDUM
February 25, 1999
TO: The Honorable Mayor and City Council Members
FROM: Michael C. Van Milligen, City Manager
SUBJECT:
Administrative Services and Financial Agreement for the Delta Dental
Plan
Human Services Manager Randy Peck is recommending approval of the
Administrative Services and Financial Agreement for the Delta Dental Plan.
I concur with the recommendation and respectfully request Mayor and City Council
approval.
Mi
MCVM/j
Attachment
cc: Barry Lindahl, Corporation Counsel
Tim Moerman, Assistant City Manager
Randy Peck, Human Services Manager
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CITY OF DUBUQUE, IOWA
MEMORANDUM
February 16, 1999
TO:
FROM:
Michael C. Van Milligen, City Manager
Randy Peck, Personnel Manager ~
SUBJECT:
Administrative Services and Financial Agreement for the Delta Dental
Plan
The Administration Fee ($2.45 per contract, per month) that went into effect on
July 1, 1998, was approved by the Health Care Committee on May 26, 1998.
However, we did not receive the Administrative Services and Financial Agreement
until January 29, 1999. The agreement has been reviewed by Corporation
Counsel Barry Lindahl and Debra Gassen of The Segal Company, and they concur
that it is in order. The Health Care Committee approved the agreement on
February 16, 1999.
I recommend that the agreement be approved and request that the City Council
pass a motion approving the agreement and authorizing you to sign the
agreement.
If you have any questions, please feel free to call.
RP/dd
THIS IS YOUR COpy
TO KEEP
ADMINISTRATIVE SERVICES and FINANCIAL AGREEMENT
THIS AGREEMENT is by and between Delta Dental Plan of Iowa
(Delta), and City of Dubuque (Employer).
WHEREAS, the following circumstances exist:
A. Delta is a nonprofit corporation authorized by the Commissioner of
Insurance for the state of Iowa to transact business as a dental service
plan.
B. Employer wishes to create or has established a dental benefits plan for
its eligible Employees.
C. This benefits plan is sponsored and funded by Employer. Employer
wishes to enter into a financial arrangement with Delta under which
Employer is solely responsible for the Benefits Expense for covered
dental services provided to its Members. Delta does not assume any
fmancial risk or obligation with respect to the Benefits Expense for
covered services provided to Members of this plan.
D. Employer desires that Delta settle claims for dental services provided to
Members and provide other administrative services.
NOW, THEREFORE, in consideration of the mutual promises and
covenants hereinafter set forth, it is hereby agreed as follows:
1. Definitions.
a. "Administrative Fee" means an amount per contract that
Delta charges the Employer and which includes allocations for
Delta's cost of administering Employer's plan and general
operating costs. The basis for calculation of Administrative Fees
for each coverage classification is shown on the Schedule of
Coverage attached to this Agreement.
b. "Administrative Services" means those services to be
performed by Delta for Employer in connection with this
Agreement, including, but not limited to the following: claims
processing, customer services, accounting services, actuarial
IA CPA 1/98 1
services, enrollment services, data processing services, and such
other related services as the parties may agree are appropriate
and necessary to accomplish the objectives of this Agreement.
Administrative Services expressly exclude any services for the
administration of continued dental coverage pursuant to the
Consolidated Omnibus Budget Reconciliation Act of 1985
(COBRA), as amended, or any state or federal law relating to
continuation coverage of the Employer's plan.
c. "Agreement" means this Administrative Services and
Financial Agreement, the Schedule of Coverage attached to it
initially and as such may be revised or amended, the Benefits
Certificate, and the Plan Members' applications for coverage.
d. "Benefits Certificate" means the written document(s) which
describe and defme a welfare benefit plan for dental services
which the Employer established for Members.
e. "Benefits Expense" means the amount calculated by adding
the Network Access Fee to Claims Settled for the month.
Following termination of the Agreement, the Network Access
Fee shall no longer apply. For dental benefits, the Benefits
Expense amount equals Claims Settled.
f. "Claims Settled" means the amount for which liability is
discharged by Delta's settlement on behalf of the Employer
without regard to the Incurred Date. This amount is calculated
by deducting from the Covered Charges any amounts
attributable to Provider Savings, deductibles, co payment,
coinsurance, or Contract Limitations as defmed in the Benefits
Certificate. The amount of Claims Settled during the Rating
Period is determined by the date of Delta's check or remittance.
For dental benefits, the Claims Settled amount equals Benefits
Expense.
g. "Contract Limitations" means the amounts which are the
liability of the Plan Member under this Agreement. These
include the services which are not covered, charges for dental
services which are not dentally necessary, penalties for failure
to follow notification requirements, and charges for services that
have reached a contract maximum.
IA CPA 1/98 2
h. "Covered Charges" means the amount a provider bills a
Member, or Delta, less services not covered. The term "Covered
Services" is defined in the Benefits Certificate.
1. "Delta Allowance" means the lesser of the Covered Charge for
a specific dental procedure and the maximum allowable fee that
Delta has established for the same dental procedure.
The maximum allowable fee is established by Delta for a covered
dental procedure that is dentally necessary and dentally
appropriate. It is developed from various sources, such as
contracts with dentists, input from our dental consultants, the
simplicity or complexity of the procedure, and the billed charges
for the same procedures by dentists in Iowa.
J. "Employee" means an active employee of Employer for
purposes of Social Security laws or who otherwise is included as
an employee as required by law (or an owner or member of the
Board of Directors of an Employer).
k. "Fixed Costs" means the total monthly fixed charge which
includes the Administrative Fee.
1. "Incurred Claims" means claims for dental services that are
furnished to Members with a date of service during the Rating
Period.
m. "Incurred Date" means the date dental services are provided.
With regard to inpatient hospital or Facility services, the date
of admission is the Incurred Date.
n. "Member" means any person entitled to receive dental benefits
as defmed in the Benefits Certificate.
o. "Plan Member" means any individual identified by Employer
as a person eligible for dental coverage subject to the terms,
conditions and limitations described in the Benefits Certificate
and who is named on an identification card issued by Delta.
p. "Provider Savings" means the amount saved due to our
contracts with providers. It is calculated as the difference
between the Covered Charge and the Delta Allowance.
IA CPA 1/98 3
q. "Rating Period" means the period of time set forth in the
Schedule of Coverage or the most recent revision to the Schedule
of Coverage.
2. The Effective Date of this Agreement is July It 1998t at 12:01
a.m.t local time. This Agreement supersedes any prior
Agreements entered into between the parties.
3. Responsibilities of Employer.
a. Furnishing Information. Employer agrees to furnish Delta
with timely reports and information in a form and manner
required by Delta so that Delta properly may discharge its
responsibilities under this Agreement, including but not limited
to, information pertaining to Members for the purpose of
determining eligibility for coverage under the Benefits
Certificate, and information necessary for the proper
administration of coordination of benefits and other limitations
and exclusions contained in the Benefits Certificate.
b. Persons Eligible for Coverage. Prior to the Effective Date
of this Agreement, Employer shall deliver to Delta a list of the
names and completed applications for each person that
Employer shall designate as being eligible for benefits set forth
in the Benefits Certificate.
On or before the first of each month thereafter Employer shall
notify Delta in writing of those persons who are no longer
eligible as of that month, and thereafter Delta shall not settle
Incurred Claims for services furnished such persons.
At any time after the Effective Date, Employer may certify to
Delta the names of additional eligible persons. Delta shall, from
and after the commencement date of coverage Delta establishes
for such persons, settle Incurred Claims with Incurred Dates on
or after the effective date of coverage in accordance with the
terms and conditions set forth in this Agreement and the
Benefits Certificate.
c. Failure to Provide Information. Employer's failure to
provide timely and accurate information may cause Delta to
make incorrect settlements. In that event, Employer may be
liable for all or part of any incorrect settlements made.
IA CPA 1/98 4
4. Settlement of Incurred Claims and Administrative Fee.
Employer authorizes Delta and Delta agrees to process Incurred
Claims on a regular basis, subject to the limitations, conditions, and
exclusions stated in the Benefits Certificate. Employer will payor
reimburse Delta for the Benefits Expense and Administrative Fee
as set forth in this paragraph.
a. Monthly Settlement. Delta will bill Employer by the twentieth
(20th) calendar day of each month. The bill will show the
amount of Benefits Expense and Administrative Fee for the
preceding month. Employer shall promptly pay Delta at Delta's
office the total shown within ten (10) days from receipt of the
bill, and in any event, no later than the last calendar day of the
month. If the due date falls on a weekend or holiday, payment
is due the preceding business day.
5. Late Payments. All payments must be paid on time in accordance
with paragraph 4. If the Employer fails to make timely payments
in full, Delta may, at its option, immediately stop the settlement of
all claims for the Employer's Members, regardless of the Incurred
Date and may terminate this Agreement retroactively to the last day
of the month for which full payment was made without any further
notice. Payments not made when due also will be subject to an
interest charge at the then prevailing prime rate plus two percent
(2%). The acceptance by Delta of any late payments or partial
payments shall not constitute a waiver of this provision.
6. Examination of Books and Records.
a. Delta may examine the financial records of Employer reasonably
related to the administration of this Agreement, upon
reasonable notice, as often as Delta deems appropriate, to
determine whether Employer has sufficient amounts on deposit
to ensure payment of Benefits Expense and Administrative Fee.
b. Employer or its authorized representative may examine or audit
Delta's records reasonably related to Delta's discharge of
Employer's liability to settle Incurred Claims. Such
examination shall be conducted during regular business hours,
upon reasonable advance written notice. Records subject to
examination shall include case listings, third-party explanations
of health care benefits, eligibility records, claims history, and
coordination of benefits procedures. The examination period
may cover the current Rating Period and the two years previous
IA CPA 1/98 5
only. Upon completion of the examination, Employer shall share
its examination findings with Delta and conduct an exit
conference with Delta.
c. It is agreed that disclosure of any information under this
paragraph to Employer or Delta has been made in reliance upon
the other party's representation that such information shall be
used by it for the sole and exclusive purpose of examining or
auditing information related to the administration of the health
care plan. Such information shall not be disclosed or otherwise
made available to any person or organization not directly
involved in the examination or audit and Delta and Employer
shall implement whatever reasonable safeguards are necessary
to ensure that such information remains confidential.
7. Change of Agreement.
a. If during the Rating Period, any material changes are made in
the health care benefits described in the Benefits Certificate,
including the addition or deletion of benefits, or material changes
are made to membership or eligibility requirements, such as an
increase in the ratio of family to single contracts of more than
twenty percent (20%), a change in the number of Employees of
more than ten percent (10%), percentage of Employees enrolled,
types of coverages offered, business entities covered, or offerings
of other health insurers' coverage to Employees, Delta shall have
the right at its option to either amend the Agreement, including
an adjustment to the fmancial terms shown on the Schedule of
Coverage, or terminate the Agreement.
b. Delta will provide Employer ninety (90) days prior written
notice of any amendment under this paragraph.
c. Changes to this Agreement will be effective only when the
written amendment has been signed by authorized
representatives of Delta and Employer.
8. Liability of the Parties.
a. Employer has the liability for all Benefits Expense for its
Members. Delta has no liability for Incurred Claims if Employer
fails to payor reimburse Delta in accordance with this
Agreement.
IA CPA 1/98 6
Employer agrees to hold harmless and indemnify Delta or any
of its directors, officers, or employees for any and all loss,
liability, damage, expense, or other cost or obligation, including
reasonable attorneys' fees, resulting from and arising out of
claims, demands, or lawsuits brought against Delta by Members,
or other persons by reason of the performance or
nonperformance of Employer's responsibilities under this
Agreement, or in connection with benefits or coverage
information disclosed at Employer's request or disclosed during
an examination or audit of books and records, provided the
directors, officers, or employees of Delta shall have performed
their duties with ordinary care and diligence and such directors,
officers, or employees of Delta shall not be liable for any mistake
of judgment or other action taken in good faith.
Delta has made a good faith determination of what the premium
tax liability shall be under this Agreement based upon Iowa
Code Chapter 432. If the governmental authority responsible
for collecting such taxes determines that additional taxes should
have been assessed for the charges collected by Delta under this
Agreement, the Employer agrees to indemnify Delta for such
liability.
b. Delta agrees to hold harmless and indemnify Employer or any
of its directors, officers, or employees for any and all loss,
liability, damage, expense, or other cost or obligation, including
reasonable attorneys' fees, resulting from and arising out of
claims, demands, or lawsuits brought against Employer by
reason of our failure to perform our responsibilities under this
Agreement (or policy).
9. Use of Trademarks. Delta and Employer reserve the right to
control the use of their respective corporate names and any other
respective symbols, assumed names, trademarks, and service marks,
presently existing or subsequently established. Delta and Employer
agree not to use the corporate name, symbol, assumed names,
trademarks, or service marks of the other in advertising, promotional
materials, or otherwise without the prior written consent of the
other. Any previously approved usage will cease immediately upon
the termination of this Agreement and any materials 'using such
names or marks are the property of the appropriate namesake and
will be returned to the appropriate property owner upon request or
at the termination of this Agreement.
IA CPA 1/98
7
10. Term and Termination.
a. Term and Notice of Termination. This Agreement shall
become effective on the Effective Date and shall continue in
force for the Rating Period. However, either party may
terminate this Agreement at any time by giving written notice
of termination delivered to the other party at least sixty (60)
days in advance of the effective date of termination.
b. Renewal Terms. The parties may agree to renew the
Agreement for successive Rating Periods as shown on the
Schedule of Coverage. Delta may change Administrative Fee,
excess loss premiums and other fmancial factors upon renewal.
This Agreement will be renewed only when a new Agreement is
signed by the parties.
c. Immediate Termination. Delta may terminate this
Agreement at any time without notice if Employer fails to make
timely and complete payments in accordance with this
Agreement, or Delta determines that the Employer has
inadequate funds to make payments required by this
Agreement. Delta may terminate the Agreement retroactively
to the last day of the month for which Employer made full
payment. Employer is solely responsible for notifying its Plan
Members of the termination of this Agreement for nonpayment
or for any other reason.
d. Effects of Termination. If Delta terminates this Agreement
for nonpayment by the Employer, Delta will not settle any
Incurred Claims beyond the effective date of the termination
regardless of when the services were received.
Any liability of either party to the other for amounts owed or owing,
or for indemnification for premium taxes under this Agreement shall
not be extinguished by the termination of this Agreement.
11. Termination and Claims Settlements. If, following termination
of this Agreement for reasons other than Employer's nonpayment,
Incurred Claims for the most recent Rating Period are submitted to
Delta for settlement in the period specified in the Bene:fits Certificate
for timely filing of claims, Delta will settle claims in accordance with
this Agreement and submit monthly bills to the Employer for the
payment of Benefits Expense and the Administrative Fee associated
IA CPA 1/98
8
with those claims. The Employer will pay all monthly bills in
accordance with the procedures set forth in paragraph 4 above.
12. Force Majeure. The parties to this Agreement shall be excused
from performance under this Agreement for any period and to the
extent they are prevented from performing under this Agreement,
as a result of an Act of God, war, civil disturbance, court order, labor
dispute, or other cause beyond its reasonable control and such
nonperformance shall not be grounds for termination or default.
13. Complete Agreement. The parties agree that this Agreement,
including all Exhibits, Benefits Certificate(s), amendments, and the
Employee's application for coverage, constitutes the complete
agreement between the parties and supersedes all related discussions
and other communications between the parties.
14. Governing Law. To the extent not superseded by the laws of the
United States, this Agreement shall be construed in accordance with
the laws of the state of Iowa. Any action in regard to this
Agreement or arising out of the terms of this Agreement shall be
instituted and litigated in the state or federal courts located in the
state of Iowa and no other.
15. Notices and Communication. Delta shall be entitled to rely upon
any communication or notice from the Employer to Delta in
connection with this Agreement to be genuine, truthful, and
accurate, and to have been authorized, signed, or issued by an officer
or agent of Employer empowered to make such representation on
behalf of the Employer.
The mailing of written notices or other communications by regular
U.S. Mail, postage prepaid, shall be deemed sufficient service for the
purpose of this Agreement if addressed to the last address furnished
in writing.
IA CPA 1/98
9
Notice to Delta may be addressed:
Delta Dental Plan of Iowa
636 Grand Avenue
Des Moines, Iowa 50309
and until another address is furnished in writing, notice to Employer
may be addressed:
City of Dubuque
City Hall
13th and Central
Dubuque, IA 52001
IN WITNESS WHEREOF, the parties have executed this Agreement,
in duplicate counterparts, each counterpart being deemed an original, on the
date stated below.
Employer
Delta Dental Plan of Iowa
By
By:C-Q-J.! ~",.
Clement S. O'Meara, D.D.S.
President & Chief
Executive Officer
-
Title
Date
Date: November 16th, 1998
IA CPA 1/98
10
SCHEDULE OF COVERAGE
After signing this
Please "rem m~
eadOSed envelope~'" .
Employer/Plan Sponsor Full Legal Name and Legal Address
City of Dubuque
City Hall
Dubuque I IA 52001
Rating Period
Rating Effective Date 7/1/89 Addendum Effective Date 7/1/98
Rating Period to Which this Addendum is Applicable
Begins 7/1/98 and Ends 6/30/99
If the effective date of this Addendum is after the beginning of the Rating Period. this Addendum
supersedes any other Addendum for the same Rating Period as of the effective date of this
Addendum and ending with the end of the Rating Period.
Excess Loss Premiums
Monthly Premium
Single
Family
Delta Dental
N/A
N/A
Administrative Fee
Monthly Fee
Single
Family
Delta Dental
$2.45
$2.45
Network Access Fee
Monthly Fee
Single
Family
Delta Dental
N/A
N/A
Weekly Transfer $13.000.00
Individual Excess Loss Coverage
Individual Excess Loss Deductible N/A
The Plan's Limit of Liability is N/A of Claims Settled in Excess of the Deductible
Lifetime Individual Maximum N/A
Covered Benefits 0 Medical
o Dental
o RXlDrugs
Aggregate Excess Loss Coverage
Aggregate Attachment Point N/A of Expected Claims Settled.
The Plan's Limit of Liability 100% of Losses in Excess of the Rating Period Aggregate Deductible.
Minimum Aggregate Deductible: $0
Maximum Reimbursement for Excess Losses: N/A
Covered Benefits 0 Medical
o Dental
o RXlDrugs
Expected Claim Factors
Covered Units
Single
Family
N/A
N/A
Losses Eligible for Reimbursement
1. 0 "12/12" means the Losses were Incurred and Settled within the Rating period.
2. 0 "Paid" means the Losses were Settled within the Rating period. Losses must have been
incurred on or after the effective date of the Agreement.
3. 0 "12/18" means the Losses were Incurred and Settled within that same Rating period or
within the six months following the end of the Rating Period.
Persons Eligible for Excess loss Coverage
1. 0 As defined in Paragraph 3 of the Agreement.
2. 0 As defined in Paragraph 3 of the Agreement,EXCEPT as follows: Those Members who are
not actively working or engaging in their normal activities on the Effective Date of this
Agreement. If on the Effective Date of this Agreement a Member is not considered an active
full-time employee. is confined in a hospital. or receiving treatment because of injury or
sickness. that persons medical expenses are not included as Losses Eligible for
Reimbursement until: the date the person returns to active full-time work; or the 15th
consecutive day after the person returns to normal activities.
3. 0 As defined in Paragraph 3 of the Agreement,EXCEPT as follows: Those Members who are
confined in a hospital or other facility. If on the Effective date of this Agreement a Member is
confined in a hospital or other facility, that person's medical expenses are not included as
Losses Eligible for Reimbursement until the date the person is discharged from the hospital or
other facility.
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AGENTS I BUSINESSES I INDIVIDUALS
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Cooyri9ht@ 1995-1999 The Chubb Corporation,
See imoortant notice,
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1/27/99
JAN-28-1999 10:47
HOLMES MURPHY
515 286 4493
P.02/03
.. ~ .,._.,"."~~".. ;c>70-~'#,"""'~" ,,;;~.;}: ':~ ';''':,r:.r;;;'
. . '.. ...............................,..,...............,.. .............,............5.1.5~2.i3~6800.. .......... THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
COMPANIES AFFORDING COVERAGE
Holmes, Murphy & Assoc
P.O. Box 9207
Des Moines, IA 50306-9207
'RODUCER
COMPANY
A
Federal Insurance
Delta Dental Plan of Iowa
2401 SE Tones Drive, #13
Ankeny IA 50021
COMPANY
B
American Int't Specialty
INSURED
COMPANY
C
I
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.
co I POUCY EFFECTIVE POLICY EXPIRATION
L TR TYPE OF INSURANCE POUCY NUMBER DATE IMM/DDIYYI DATE IMMIOOIYYI
COMPANY
D
UMITS
A I EXCESS UABILlTY
rx1 UMBRELLA FORM
OTHER THAN UMBRelLA FORM
WORKERS COMPl!NSATlON AND
EMPLOYERS' UABlUTY
79760138
4/10/98 4/10/99 GENERAL AGGREGATE I $ 2000000
PRODUCTS - COMPIOP AGG $ 2000000
PERSONAl a. ADV INJURY 1000000
EACH OCCURRENCE 1000000
FIRE DAMAGE (Anyone firel 100000
MED EXP {Anyone personl 5000
COMBINED SINGLE LIMIT
BODILY INJURY
(Per person)
BODILY INJURY I $
(Per accident)
PROPERTY DAMAGE
AUTO ONLY. EA ACCIDENT
OTHER THAN AUTO ONLY:
EACH ACCIDENT .
AGGREGATE, $
4/10/98 4/10/99 EACH OCCURRENCE 1000000
AGGREGATE $ 1000000
A ~ERAL UABIUTY
I X I COMMERCiAl GENERAL LIABILITY
, CLAIMS MADE 0 OCCUR
OWNER'S & CONTRACTOR'S PRDT
35357170
AUTOMOBILE UABlUTY
ANY AUTO
ALL OWNEO AUTOS
: SCHEDULED AUTOS
HIRED AUTOS
NON-OWNED AUTOS
GARAGE UABIUTY
ANY AUTO
THE PROPRIETORI
PARTNERS/EXECUTIVE
OFFICERS ARE:
BOTHER
Professional
I Liability
I
INCL
EXCl
EL DISEASE. POLICY liMIT
El DISEASE. EA EMPLOYEE
009124183
1/01/99
1/01/00
$3,000,000 Limit
$3,000,000 Aggregate
$250.000 Deductible
DESCRIPTION OF OPERATIONS/lOCATIONSNEHICLESISPECIAL ITEMS
~~n.f@.\I~m~:!fll.*fffiII{r{:rti'i'}~ttIt:}f}iI}f::::}::It::r}:{rW}:::Wirr{::::im},:})iJ::::{:@~I~lt".t.(~nit\r::rri:I{r::r:{rl~:{{::m\::m:::'i:::::IWm:!&I,::I{mmli':~):;:(~,
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....:...:-..:.;;....:.:<.:.:.:.>-.
City of Dubuque
50 West 13th Street
Dubuque, IA 52001
SHOULD ANY OF THE ABOVE DESCIllBED POLICIES lIE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF. THE ISSUING COMPANY Will ENDEAVOR TO MAIL
~ DAYS WIlITTEN NOTICE TO THE CERTIACATE HOLDER NAMED TO THE LEFT.
BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBUGATION OR UABlUTY
JAN-28-1999 10:49
HOLMES MURPHY
515 286 4493 P.03/03
~
HOLMES
MURPHY
January 28, 1999
City of Dubuque
50 West 13th Street
Dubuque, IA 52001
RE: Delta Dental Plan of Iowa
To Whom It May Concern:
Please let this letter serve as verification that as of January 28,
1999, no claims have been reported for any of the above's current
insurance liability policies.
If there are any questions regarding this transmittal, feel free to
give me a call.
Sincerely,
Gary Hoversten
Account Manager
(515) 223-6922
cc: Delta Dental Plan of Iowa
Holmes Murphy
420 Keo Way 0 Des Moines, Iowa 50309-1638 0 (515) 286-4400 0 FAX (515) 286-4494
TOTAL P. 03
':~t~=r@"""'"
TIllS BINDER IS A TEMPORARY INSURANCE CONTRACT, SUBJECf TO TIlE CONDmONS SHOWN ON TIlE REVERSE
SIDE OF TIIIS FORM.
PRODUCER PHONE(AIC,No,Exl):
Holmes. Murphy & Assoc
DATE
TIME
X AM
515-286-4400
COMPANY
AIG/lllinois National
EFFECTIVE
420 Keo Way
Des Moines. IA 50309
1/01/99
12:01
4/01/99
CODE:
AGENCYCUSTOMERID: 083476
INSURED
Delta Dental Plan of Iowa
SUB CODE:
PM
TIDS BINDER IS ISSUED TO EXTEND COVERAGE IN THE ABOVE NAMED
COMPANY PER EXPIRING pOLICY ,:
DESCRIPTION OF OPERATIONSIVEHlCLESlPROPERTY (including LocadoD)
Professional Coverages
2401 SE Tones Drive, #13
Ankeny IA
50021
TYPE OF INSURANCE COVERAGEIFORMS AMOUNT DEDUCTIBLE COINS 'lI>
PROPERTY CAUSES OF LOSS
BASIC 0 BROAD 0 SPEC
GENERAL LIABILITY
COMM. GENERAL LIABILITY
S MADE DOCCUR
OWNER'S&CONTRACTOR'S PROT
GENERAL AGGREGATE
PROD.. COMP/OP AGG.
PERS." ADV.lN.JlJllY
EACH OCCURRENCE
FIRE DAMAGE(One FIR)
RETRO DATE FOR CLAIMS MADE:
)
COMBINED SINGLE LIMIT
BODILY INJ .(per Penon)
BODILY INJ. (Per Ace.)
PROPERTY DAMAGE
MEDICAL PAYMENTS
PERSONAL IN.JlJllY PROT .
UNINSURED MOTORIST
AUTOMOBILE LIABILITY
ANY AUTO
ALL OWNED AUTOS
SCHEDULED AUTOS
HIRED AUTOS
NON.()WNED AUTOS
AUTO PHYSICAL DAMAGE
DEDUCTIBLE
ALL VEHICLES
SCHEDULED VEHICLES
ACTUAL CASH VALUE
STATED AMOUNT
OTHER
AUTO ONLY.EA ACCIDENT
OTHER TIlAN AUTO ONLY:
EACH ACCIDENT
AGGREGATE
EACH OCCURRENCE
AGGREGATE
SELF.INSURED RETEN.
STATUTORY LIMITS tttttlMMMMitt::::=MM))
EACH ACCIDENT
DlSEASE.pOLlCY LIMIT
DISEASE.EACH EMPL.
Professional Liability - $3.000,000
Financial Institution Bond - $1,000,000
COLLISION:
OTHER TIlAN COL:
GARAGE LIABILITY
ANY AUTO
EXCESS LIABILITY
UMBRELLA FORM
OTHER TIlAN UMBRELLA FORM
RETRO DATE FOR CLAIMS MADE:
WORKER'S COMPENSATION
AND
EMPLOYER'S LIABILITY
SPECIAL Directors & Officers - $5,000,000
~iTlOSSI Fiduciary. $1,000,000
COVERAGES
AN~
CONDITIONS
This Company binds the kind(s) of insurance stipulated on the reverse side. The Insurance is subject to the
terms, conditions and limitations of the policy(ies) in current use by the Company.
This binder may be cancelled by the Insured by surrender of this binder or by written notice to the Company
stating when cancellation will be effective. This binder may be cancelled by the Company by notice to the
Insured in accordance with the policy conditions. This binder is cancelled when replaced by a policy. If the
binder is not replaced by a policy, the Company is entitled to charge a premium for the binder according to the
Rules and Rates in use by the Company.
Applicable in Delaware
The mortgagee or Obligee of any mortgage or other instrument given for the purpose of creating a lien on real
property shall accept as evidence of insurance a written binder issued by an authorized insurer or its agent if
the binder includes or is accompanied by: the name and address of the borrower; the name and address of the
lender as loss payee; a description of the insured real property; a provision that the binder may not be cancelled
within the term of the binder unless the lender and the insured borrower receive written notice of the cancel-
lation at least ten (10) days prior to the cancellation; except in the case of a renewal of a policy subsequent to
the closing of the loan, a paid receipt of the full amount of the applicable premium, and the amount of
insurance coverage.
Chapter 21 Title 25 Paragraph 2119
Applicable in Nevada
Any person who refuses to accept a binder which provides coverage of less than $1,000,000.00 when proof is
required: (A) Shall be fmed not more than $500.00, and (B) is liable to the party presenting the binder as proof
of insurance for actual damages sustained therefrom.
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=:::::::::i':::i:t:::ii\Hi:ttttift
DEC-09-1998 09:24 HOLMES MURPHY
AccessAIG - Financial ratings
.
515 286 4493 P.02/04
Page 1 of I
The American International Companies are member companies of American International Group, Inc. (AIG).
AIG is the leading U.S.-based international Insurance organization and among the largest underwriters of
commercial and industrial insurance in the United States. Member Companies of the AIG domestic
intercompany pool hold the highest poSSible ratings from the major independent ratings services, A++
(Superior) from the AM. Best Company for operating performance and financial strength, AAA (extremely
strong) from Standard & Poor's, and Aaa (exceptional) from Moody's for financial strength.
. ../bv .cgi ?BV _EngineID=caldfdemldmbejkcghecggkdnf6&BV _ Operation=Dyn_ SmartLinkRece 12/9/98
THIS IS YOUR COpy
TO KEEP
ADMINISTRATIVE SERVICES and FINANCIAL AGREEMENT
THIS AGREEMENT is by and between Delta Dental Plan of Iowa
(Delta), and City of Dubuque (Employer).
WHEREAS, the following circumstances exist:
A. Delta is a nonprofit corporation authorized by the Commissioner of
Insurance for the state of Iowa to transact business as a dental service
plan.
B. Employer wishes to create or has established a dental benefits plan for
its eligible Employees.
C. This benefits plan is sponsored and funded by Employer. Employer
wishes to enter into a fmancial arrangement with Delta under which
Employer is solely responsible for the Benefits Expense for covered
dental services provided to its Members. Delta does not assume any
fmancial risk or obligation with respect to the Benefits Expense for
covered services provided to Members of this plan.
D. Employer desires that Delta settle claims for dental services provided to
Members and provide other administrative services.
NOW, THEREFORE, in consideration of the mutual promises and
covenants hereinafter set forth, it is hereby agreed as follows:
1. Definitions.
a. "Administrative Fee" means an amount per contract that
Delta charges the Employer and which includes allocations for
Delta's cost of administering Employer's plan and general
operating costs. The basis for calculation of Administrative Fees
for each coverage classification is shown on the Schedule of
Coverage attached to this Agreement.
b. "Administrative Services" means those services to be
performed by Delta for Employer in connection with this
Agreement, including, but not limited to the following: claims
processing, customer services, accounting services, actuarial
IA CPA 1/98 1
services, enrollment services, data processing services, and such
other related services as the parties may agree are appropriate
and necessary to accomplish the objectives of this Agreement.
Administrative Services expressly exclude any services for the
administration of continued dental coverage pursuant to the
Consolidated Omnibus Budget Reconciliation Act of 1985
(COBRA), as amended, or any state or federal law relating to
continuation coverage of the Employer's plan.
c. "Agreement" means this Administrative Services and
Financial Agreement, the Schedule of Coverage attached to it
initially and as such may be revised or amended, the Benefits
Certificate, and the Plan Members' applications for coverage.
d. "Benefits Certificate" means the written document(s) which
describe and defme a welfare benefit plan for dental services
which the Employer established for Members.
e. "Benefits Expense" means the amount calculated by adding
the Network Access Fee to Claims Settled for the month.
Following termination of the Agreement, the Network Access
Fee shall no longer apply. For dental benefits, the Benefits
Expense amount equals Claims Settled.
f. "Claims Settled" means the amount for which liability is
discharged by Delta's settlement on behalf of the Employer
without regard to the Incurred Date. This amount is calculated
by deducting from the Covered Charges any amounts
attributable to Provider Savings, deductibles, copayment,
coinsurance, or Contract Limitations as defined in the Benefits
Certificate. The amount of Claims Settled during the Rating
Period is determined by the date of Delta's check or remittance.
For dental benefits, the Claims Settled amount equals Benefits
Expense.
g. "Contract Limitations" means the amounts which are the
liability of the Plan Member under this Agreement. These
include the services which are not covered, charges for dental
services which are not dentally necessary, penalties for failure
to follow notification requirements, and charges for services that
have reached a contract maximum.
IA CPA 1/98 2
h. "Covered Charges" means the amount a provider bills a
Member, or Delta, less services not covered. The term "Covered
Services" is defmed in the Benefits Certificate.
i. "Delta Allowance" means the lesser of the Covered Charge for
a specific dental procedure and the maximum allowable fee that
Delta has established for the same dental procedure.
The maximum allowable fee is established by Delta for a covered
dental procedure that is dentally necessary and dentally
appropriate. It is developed from various sources, such as
contracts with dentists, input from our dental consultants, the
simplicity or complexity of the procedure, and the billed charges
for the same procedures by dentists in Iowa.
J. "Employee" means an active employee of Employer for
purposes of Social Security laws or who otherwise is included as
an employee as required by law (or an owner or member of the
Board of Directors of an Employer).
k. "Fixed Costs" means the total monthly fixed charge which
includes the Administrative Fee.
1. "Incurred Claims" means claims for dental services that are
furnished to Members with a date of service during the Rating
Period.
m. "Incurred Date" means the date dental services are provided.
With regard to inpatient hospital or Facility services, the date
of admission is the Incurred Date.
n. "Member" means any person entitled to receive dental benefits
as defmed in the Benefits Certificate.
o. "Plan Member" means any individual identified by Employer
as a person eligible for dental coverage subject to the terms,
conditions and limitations described in the Benefits Certificate
and who is named on an identification card issued by Delta.
p. "Provider Savings" means the amount saved due to our
contracts with providers. It is calculated as the difference
between the Covered Charge and the Delta Allowance.
IA CPA 1/98 3
q. "Rating Period" means the period of time set forth in the
Schedule of Coverage or the most recent revision to the Schedule
of Coverage.
2. The Effective Date of this Agreement is July 1, 1998, at 12:01
a.m., local time. This Agreement supersedes any prior
Agreements entered into between the parties.
3. Responsibilities of Employer.
a. Furnishing Information. Employer agrees to furnish Delta
with timely reports and information in a form and manner
required by Delta so that Delta properly may discharge its
responsibilities under this Agreement, including but not limited
to, information pertaining to Members for the purpose of
determining eligibility for coverage under the Benefits
Certificate, and information necessary for the proper
administration of coordination of benefits and other limitations
and exclusions contained in the Benefits Certificate.
b. Persons Eligible for Coverage. Prior to the Effective Date
of this Agreement, Employer shall deliver to Delta a list of the
names and completed applications for each person that
Employer shall designate as being eligible for benefits set forth
in the Benefits Certificate.
On or before the first of each month thereafter Employer shall
notify Delta in writing of those persons who are no longer
eligible as of that month, and thereafter Delta shall not settle
Incurred Claims for services furnished such persons.
At any time after the Effective Date, Employer may certify to
Delta the names of additional eligible persons. Delta shall, from
and after the commencement date of coverage Delta establishes
for such persons, settle Incurred Claims with Incurred Dates on
or after the effective date of coverage in accordance with the
terms and conditions set forth in this Agreement and the
Benefits Certificate.
c. Failure to Provide Information. Employer's failure to
provide timely and accurate information may cause Delta to
make incorrect settlements. In that event, Employer may be
liable for all or part of any incorrect settlements made.
IA CPA 1/98 4
4. Settlement of Incurred Claims and Administrative Fee.
Employer authorizes Delta and Delta agrees to process Incurred
Claims on a regular basis, subject to the limitations, conditions, and
exclusions stated in the Benefits Certificate. Employer will payor
reimburse Delta for the Benefits Expense and Administrative Fee
as set forth in this paragraph.
a. Monthly Settlement. Delta will bill Employer by the twentieth
(20th) calendar day of each month. The bill will show the
amount of Benefits Expense and Administrative Fee for the
preceding month. Employer shall promptly pay Delta at Delta's
office the total shown within ten (10) days from receipt of the
bill, and in any event, no later than the last calendar day of the
month. If the due date falls on a weekend or holiday, payment
is due the preceding business day.
5. Late Payments. All payments must be paid on time in accordance
with paragraph 4. If the Employer fails to make timely payments
in full, Delta may, at its option, immediately stop the settlement of
all claims for the Employer's Members, regardless of the Incurred
Date and may terminate this Agreement retroactively to the last day
of the month for which full payment was made without any further
notice. Payments not made when due also will be subject to an
interest charge at the then prevailing prime rate plus two percent
(2%). The acceptance by Delta of any late payments or partial
payments shall not constitute a waiver of this provision.
6. Examination of Books and Records.
a. Delta may examine the financial records of Employer reasonably
related to the administration of this Agreement, upon
reasonable notice, as often as Delta deems appropriate, to
determine whether Employer has sufficient amounts on deposit
to ensure payment of Benefits Expense and Administrative Fee.
b. Employer or its authorized representative may examine or audit
Delta's records reasonably related to Delta's discharge of
Employer's liability to settle Incurred Claims. Such
examination shall be conducted during regular business hours,
upon reasonable advance written notice. Records subject to
examination shall include case listings, third-party explanations
of health care benefits, eligibility records, claims history, and
coordination of benefits procedures. The examination period
may cover the current Rating Period and the two years previous
IA CPA 1/98 5
only. Upon completion of the examination, Employer shall share
its examination findings with Delta and conduct an exit
conference with Delta.
c. It is agreed that disclosure of any information under this
paragraph to Employer or Delta has been made in reliance upon
the other party's representation that such information shall be
used by it for the sole and exclusive purpose of examining or
auditing information related to the administration of the health
care plan. Such information shall not be disclosed or otherwise
made available to any person or organization not directly
involved in the examination or audit and Delta and Employer
shall implement whatever reasonable safeguards are necessary
to ensure that such information remains confidential.
7. Change of Agreement.
a. If during the Rating Period, any material changes are made in
the health care benefits described in the Benefits Certificate,
including the addition or deletion of benefits, or material changes
are made to membership or eligibility requirements, such as an
increase in the ratio of family to single contracts of more than
twenty percent (20%), a change in the number of Employees of
more than ten percent (10%), percentage of Employees enrolled,
types of coverages offered, business entities covered, or offerings
of other health insurers' coverage to Employees, Delta shall have
the right at its option to either amend the Agreement, including
an adjustment to the fmancial terms shown on the Schedule of
Coverage, or terminate the Agreement.
b. Delta will provide Employer ninety (90) days prior written
notice of any amendment under this paragraph.
c. Changes to this Agreement will be effective only when the
written amendment has been signed by authorized
representatives of Delta and Employer.
8. Liability of the Parties.
a. Employer has the liability for all Benefits Expense for its
Members. Delta has no liability for Incurred Claims if Employer
fails to payor reimburse Delta in accordance with this
Agreement.
IA CPA 1/98 6
Employer agrees to hold harmless and indemnify Delta or any
of its directors, officers, or employees for any and all loss,
liability, damage, expense, or other cost or obligation, including
reasonable attorneys' fees, resulting from and arising out of
claims, demands, or lawsuits brought against Delta by Members,
or other persons by reason of the performance or
nonperformance of Employer's responsibilities under this
Agreement, or in connection with benefits or coverage
information disclosed at Employer's request or disclosed during
an examination or audit of books and records, provided the
directors, officers, or employees of Delta shall have performed
their duties with ordinary care and diligence and such directors,
officers, or employees of Delta shall not be liable for any mistake
of judgment or other action taken in good faith.
Delta has made a good faith determination of what the premium
tax liability shall be under this Agreement based upon Iowa
Code Chapter 432. If the governmental authority responsible
for collecting such taxes determines that additional taxes should
have been assessed for the charges collected by Delta under this
Agreement, the Employer agrees to indemnify Delta for such
liability.
b. Delta agrees to hold harmless and indemnify Employer or any
of its directors, officers, or employees for any and all loss,
liability, damage, expense, or other cost or obligation, including
reasonable attorneys' fees, resulting from and arising out of
claims, demands, or lawsuits brought against Employer by
reason of our failure to perform our responsibilities under this
Agreement (or policy).
9. Use of Trademarks. Delta and Employer reserve the right to
control the use of their respective corporate names and any other
respective symbols, assumed names, trademarks, and service marks,
presently existing or subsequently established. Delta and Employer
agree not to use the corporate name, symbol, assumed names,
trademarks, or service marks of the other in advertising, promotional
materials, or otherwise without the prior written consent of the
other. Any previously approved usage will cease immediately upon
the termination of this Agreement and any materials 'using such
names or marks are the property of the appropriate namesake and
will be returned to the appropriate property owner upon request or
at the termination of this Agreement.
IA CPA 1/98
7
10. Term and Termination.
a. Term and Notice of Termination. This Agreement shall
become effective on the Effective Date and shall continue in
force for the Rating Period. However, either party may
terminate this Agreement at any time by giving written notice
of termination delivered to the other party at least sixty (60)
days in advance of the effective date of termination.
b. Renewal Terms. The parties may agree to renew the
Agreement for successive Rating Periods as shown on the
Schedule of Coverage. Delta may change Administrative Fee,
excess loss premiums and other fmancial factors upon renewal.
This Agreement will be renewed only when a new Agreement is
signed by the parties.
c. Immediate Termination. Delta may terminate this
Agreement at any time without notice if Employer fails to make
timely and complete payments in accordance with this
Agreement, or Delta determines that the Employer has
inadequate funds to make payments required by this
Agreement. Delta may terminate the Agreement retroactively
to the last day of the month for which Employer made full
payment. Employer is solely responsible for notifying its Plan
Members of the termination of this Agreement for nonpayment
or for any other reason.
d. Effects of Termination. If Delta terminates this Agreement
for nonpayment by the Employer, Delta will not settle any
Incurred Claims beyond the effective date of the termination
regardless of when the services were received.
Any liability of either party to the other for amounts owed or owing,
or for indemnification for premium taxes under this Agreement shall
not be extinguished by the termination of this Agreement.
11. Termination and Claims Settlements. If, following termination
of this Agreement for reasons other than Employer's nonpayment,
Incurred Claims for the most recent Rating Period are submitted to
Delta for settlement in the period specified in the BenE:flts Certificate
for timely filing of claims, Delta will settle claims in accordance with
this Agreement and submit monthly bills to the Employer for the
payment of Benefits Expense and the Administrative Fee associated
IA CPA 1/98
8
with those claims. The Employer will pay all monthly bills in
accordance with the procedures set forth in paragraph 4 above.
12. Force Majeure. The parties to this Agreement shall be excused
from performance under this Agreement for any period and to the
extent they are prevented from performing under this Agreement,
as a result of an Act of God, war, civil disturbance, court order, labor
dispute, or other cause beyond its reasonable control and such
nonperformance shall not be grounds for termination or default.
13. Complete Agreement. The parties agree that this Agreement,
including all Exhibits, Benefits Certificate(s), amendments, and the
Employee's application for coverage, constitutes the complete
agreement between the parties and supersedes all related discussions
and other communications between the parties.
14. Governing Law. To the extent not superseded by the laws of the
United States, this Agreement shall be construed in accordance with
the laws of the state of Iowa. Any action in regard to this
Agreement or arising out of the terms of this Agreement shall be
instituted and litigated in the state or federal courts located in the
state of Iowa and no other.
15. Notices and Communication. Delta shall be entitled to rely upon
any communication or notice from the Employer to Delta in
connection with this Agreement to be genuine, truthful, and
accurate, and to have been authorized, signed, or issued by an officer
or agent of Employer empowered to make such representation on
behalf of the Employer.
The mailing of written notices or other communications by regular
U.S. Mail, postage prepaid, shall be deemed sufficient service for the
purpose of this Agreement if addressed to the last address furnished
in writing.
IA CPA 1/98
9
Notice to Delta may be addressed:
Delta Dental Plan of Iowa
636 Grand A venue
Des Moines, Iowa 50309
and until another address is furnished in writing, notice to Employer
may be addressed:
City of Dubuque
City Hall
13th and Central
Dubuque, IA 52001
IN WITNESS WHEREOF, the parties have executed this Agreement,
in duplicate counterparts, each counterpart being deemed an original, on the
date stated below.
Employer
Delta Dental Plan of Iowa
By-flv11 ~;1/L
Title C;/y 171C!/V(J1.p~
J -~. ~ r
BY:CO-...J>.! ~_" 'r
Clement S. O'Meara, D.D.S.
President & Chief
Executive Officer
---
Date
Date: November 16th, 1998
IA CPA 1/98
10
SCHEDULE OF COVERAGE
After signing this
.....__..._~
P1casc ICtum m thc._~
eodOsed envelope~".
Employer/Plan Sponsor Full Legal Name and Legal Address
City of Dubuque
City Hall
Dubuque, fA 52001
Rating Period
Rating Effective Date 7/1/89 Addendum Effective Date 7/1/98
Rating Period to Which this Addendum is Applicable
Begins 7/1/98 and Ends 6/30/99
If the effective date of this Addendum is after the beginning of the Rating Period. this Addendum
supersedes any other Addendum for the same Rating Period as of the effective date of this
Addendum and ending with the end of the Rating Period.
Excess Loss Premiums
Monthly Premium
Single
Family
Delta Dental
N/A
N/A
Administrative Fee
Monthly Fee
Single
Family
Delta Dental
$2.45
$2.45
Network Access Fee
Monthly Fee
Single
Family
Delta Dental
N/A
N/A
Weekly Transfer $13,000.00
Individual Excess Loss Coverage
Individual Excess Loss Deductible N/A
The Plan's Limit of Liability is N/A of Claims Settled in Excess of the Deductible
Lifetime Individual Maximum N/A
Covered Benefits 0 Medical
o Dental
o RXlDrugs
Aggregate Excess loss Coverage
Aggregate Attachment Point N/A of Expected Claims Settled.
The Plan's Limit of Liability 100% of Losses in Excess of the Rating Period Aggregate Deductible.
Minimum Aggregate Deductible: $0
Maximum Reimbursement for Excess Losses: N/A
Covered Benefits 0 Medical
o Dental
o RXlDrugs
Expected Claim Factors
Covered Units
Single
Family
N/A
N/A
Losses Eligible for Reimbursement
1. 0 "12/12" means the Losses were Incurred and Settled within the Rating period.
2. 0 "Paid" means the Losses were Settled within the Rating period. Losses must have been
incurred on or after the effective date of the Agreement.
3. 0 "12/18" means the Losses were Incurred and Settled within that same Rating period or
within the six months following the end of the Rating Period.
Persons Eligible for Excess loss Coverage
1. 0 As defined in Paragraph 3 of the Agreement.
2. 0 As defined in Paragraph 3 of the Agreement.EXCEPT as follows: Those Members who are
not actively working or engaging in their normal activities on the Effective Date of this
Agreement. If on the Effective Date of this Agreement a Member is not considered an active
full-time employee. is confined in a hospital. or receiving treatment because of injury or
sickness. that persons medical expenses are not included as Losses Eligible for
Reimbursement until: the date the person returns to active full-time work; or the 15th
consecutive day after the person returns to normal activities.
3. 0 As defined in Paragraph 3 of the Agreement.EXCEPT as follows: Those Members who are
confined in a hospital or other facility. If on the Effective date of this Agreement a Member is
confined in a hospital or other facility I that person's medical expenses are not included as
Losses Eligible for Reimbursement until the date the person is discharged from the hospital or
other facility.
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::~~~"*>;~;';$.-;.::::::':::~:x:('::::XX-;X}":>;:'X:,*~x>;'S::::'WX:>;*::'~~=i-*::::::::::'"?;W::::(.xi$X*:-;*>;,>>..-:;~~>>k:-:-'$-;fI'h::x::::i:)X;I'@::n-.m:~."':$:.~~"':.'$::::;."i<<-::x::x:~::;."
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AGENTS I BUSINESSES I INDIVIDUALS
INVESTORS I CAREERS
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CoPyri9ht @ 1995-1999 The Chubb Corporation.
See important notice.
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http://www.chubb.com/businesses/ surety !ratings, html
1/27/99
JAN-28-1999 10:47
HOLMES MURPHY
515 286 4493
P.02/03
.)i?:qi!~~]_...""'j,'J~~~;;'
'RoiiuCER' .......... ......................,....-..............................5.i"6.~2'23~6i:ioo............ THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
COMPANIES AFFORDING COVERAGE
Holmes, Murphy & Assoc
P.O. Box 9207
Des Moines, lA 50306-9207
COMPANY
A
Federal Insurance
Delta Dental Plan of Iowa
2401 SE Tones Drive, #13
Ankeny IA 50021
COMPANY
B
American Int'l Specialty
INSURED
COMPANY
C
COMPANY
D
I
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.
CO
LTR
TYPE OF INSURANCE
POUCY NUMBER
POUCY EFFECTIVE POUCY EXPlRAnON
DATE IMMIDDIVYI DATE lMMlDDIVYI
UMITS
A ~ERAL LIABILITY
I X I COMMERCIAL GENERAL LIABILITY
. 1 CLAIMS MADE [8] OCCUR
f.--- OWNER'S" CONTRACTOR'S PROT
f.---
36357170
4/10/98
4/10/99
GENERAL AGGREGATE $
PRODUCTS COMPIOP AGG $
PERSONAL & ADV INJURY $
EACH OCCURRENCE $
FIRE DAMAGE (Anyone fjre) $
2000000
2000000
1000000
1000000
100000
MED EXP (Anyone person)
5000
~TOMOBILE UA81UTY
~ ANY AUTO
I-- ALL OWNED AUTOS
_ SCHEDULED AUTOS
_ HIRED AUTOS
_ NON-OWNED AUTOS
-
COMBINED SINGLE LIMIT
BODILY INJURY
(Per porson)
BODILY INJURY
lPe, occident)
PROPERTY DAMAGE
~GE UABIUTV
I-- ANY AUTO
AUTO ONLY EA ACCIDENT
OTHER THAN AUTO ONLY:
EACH ACCIDENT $
f.---
AGGREGATE $
I TWC STATU-
EL EACH ACCIDENT
$
$
$
IOJ~-.....
$
1000000
1000000
A EXCESS lIABlUTY
-xl. UMBRELLA FORM
I OTHER THAN UMBRELLA FORM
WORKERS COMPENSAnON AND
EMPLOYERS' lIABlUTV
79760138
4/10/98
4/10/99
EACH OCCURRENCE
AGGREGATE
THE PROPRIETOR!
PARTNERS/EXECUTIVE
OFFICERS ARE:
BOTHER
Professional
liability
RINCL
EXCL
EL DISEASE POLICY LIMIT $
EL DISEASE EA EMPLOYEE $
009124183
1/01/99
1/01/00
I
\
$3,000,000 Limit
$3.000.000 Aggregate
$250,000 Deductible
DESCRIPTION OF OPERATIONSILOCAnONS/VEHICLESISPECIAL ITEMS
~@fi1~@#.tf~:~:$.~..l.iffm%:mtrr~l:{~;m:::~}'Wr;I{;:mrl::\:I:;:m:::mm{~:mmmm{WrI;f:lm:h{::f::{:@~'-'.t;mi;At.@'t{:::;:{]~:tff:I:ttt:tffit:t::\t:::?t:\ff?'j")
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPlRAnON DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO MAIL
30 DAYS WRI1TEN NonCE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT.
BUT FAILURE TO MAU. SUCH NonCE SHALL IMPOSI: NO OBUGATION OR L1ABlUTY
OF NIY KIND ~N THE COMPANY, ITS AGENTS OR REPRESENTATIVES.
AUTH -V.lt~~ . ,. ./
~A~i1t~j,.~".UtJf!mWHminM@llliX1i!iMWi;:ttlmMifit\UimWn::::mIw@@~:imwim~~~MM:W:!Wnl}}:l:~:'Wft:JIIj:fWi!4..MiJ..COijijO'AA1.9.1\1,;1$8$
City of Dubuque
50 West 13th Street
Dubuque, IA 52001
JAN-28-1999 10:49
HOLMES MURPHY
515 286 4493 P.03/03
~
HOLMES
MURPHY
January 28, 1999
City of Dubuque
50 West 13th Street
Dubuque, IA 52001
RE: Delta Dental Plan of Iowa
To Whom It May Concern:
Please let this letter serve as verification that as of January 28,
1999, no claims have been reported for any of the above's current
insurance liability policies.
If there are any questions regarding this transmittal, feel free to
give me a call.
Sincerely,
Gary Hoversten
Account Manager
(515) 223-6922
cc: Delta Dental Plan of Iowa
Holmes Murphy
420 Keo Way [J Des Moines. Iowa 50309-1638 [J (515) 286-4400 0 FAX (515) 286-4494
TOTAL P.03
-
....................'.....
.:.;.;.:.;.:.:.:.:.:.;.:.:.:.:.:.;.:.;.;
:;::::;::;:;:;:;:;:::::;:;:;:;:;:;:;:;:::: .:.::;:;=;=;:;=;::::::;::;'
:::{;;::):;:~~~~;~;~~~f~i:;)f:~~r~~~ttt~~
:~fmtmtrmtt?tt1f~t~ft~t
..........................
.............................
. ...............................
...................................,......................
DATE (MMJDDiYYl
12/30/98
THIS BINDER IS A TEMPORARY INSURANCE CONTRACT, SUBJECT TO THE CONDmONS SHOWN ON THE REVERSE
SIDE OF THIS FORM,
PRODUCER PHONE(A1C,No,Ext):
Holmes. Murphy & Assoc
DATE
515-286-4400
COMPANY
AIG/lllinois National
EFFECTIVE
420 Keo Way
Des Moines, IA 50309
AM
1/01/99
12:01
4/01/99
CODE:
AGENCYCUSTOMERID: 083476
INSURED
Delta Dental Plan of Iowa
SUB CODE,
PM
TlDS BINDER IS ISSUED TO EXTEND COVERAGE IN THE ABOVE NAMED
COMPANY PER EXPIRING POUCY I:
DESClUl'TION OF OPERATlONSIVEHICLESJPROPERTY (IncIulliDl LocalIoa)
Professional Coverages
2401 SE Tones Drive, #13
Ankeny IA
50021
::m9.~M9.~rt:rmt::t::t::tt::::t:::r::::m:r:t::::tt:::::::::rr:mr:tt:rr::::::::::::r:mrm::::::mmt:r:::::ttt::tt:::r::r:::;::::tt:rmmmmmt:m:rrr::r:::::tmmtt::::t:::r:ttjtt:r::::::r:
TYPE OF INSURANCE COVERAGEIFORMS
PROPERTY CAUSES OF LOSS
BASIC D BROAD D SPEC
..::t:::::::::rrrr::r:::::::::t::::ttt:{:::~r:mr:::::::::ttf:::::::::::::::::::::' . ...
AMOUNT DEDUCTIBLE COINS 'le
RETRO DATE FOR CLAIMS MADE:
GENERAL AGGREGATE
PROD.. COMP/OP AGG.
PERS." ADV.INlURY
EACH OCCURRENCE
FIRE DAMAGE(Ooe FIre)
MED EXP(AD ODe noD)
COMBINED SINGLE LIMIT
BODILY 1N1.(Per Penon)
BODILY 00. (Per Ace.)
PROPERTY DAMAGE
MEDICAL PAYMENTS
PERSONAL INlURY PROT .
UNINSURED MOTORIST
GENERAL UABILITY
COMM. GENERAL UABILITY
LAIMS MADE DOCCUR
OWNER'S"CONTRACTOR'S PROT
AUTOMOBILE UABILITY
ANY AUTO
ALL OWNED AUTOS
NON.QWNED AUTOS
AUTO PHYSICAL DAMAGE
DEDUCTIBLE
ALL VEHICLES
SCHEDULED VEHICLES
ACTUAL CASH VALUE
STATED AMOUNT
OTHER
AUTO ONLY.EA ACCIDENT
OTHER TIIAN AUTO ONLY:
EACH ACCIDENT
AGGREGATE
EACH OCCURRENCE
AGGREGATE
SELF-INSURED RETEN.
STATUTORY LIMITS
EACH ACCIDENT
DISEASE-POUCY LIMIT
DISEASE-EACH EMPL.
Professional Liability. $3,000.000
Financial Institution Bond. $1.000,000
COLUSION:
OTHER TIIAN COLI
GARAGE UABILITY
ANY AUTO
EXCESS UABILITY
UMBRELLA FORM
OTHER TIIAN UMBRELLA FORM
RETRO DATE FOR CLAIMS MADE:
WORKER'S COMPENSATION
AND
DlPLOYER'S LIABILITY
SPECIAL
CONDITlONSI
OTHER
COVERAGES
Directors & Officers - $5,000,000
Fiduciary - $1,000,000
'Nd;~
.....................................
':;:;=::::::::::;=;::=;=:::::::::::::=;:;:;=:=::::::;:;:::;:;:;:;:;:;"
.":;:
CONDITIONS
This Company binds the kind(s) of insurance stipulated on the reverse side. The Insurance is subject to the
terms, conditions and limitations of the policy(ies) in current use by the Company.
This binder may be cancelled by the Insured by surrender of this binder or by written notice to the Company
stating when cancellation will be effective. This binder may be cancelled by the Company by notice to the
Insured in accordance with the policy conditions. This binder is cancelled when replaced by a policy. If the
binder is not replaced by a policy, the Company is entitled to charge a premium for the binder according to the
Rules and Rates in use by the Company.
Applicable in Delaware
The mortgagee or Obligee of any mortgage or other instrument given for the purpose of creating a lien on real
property shall accept as evidence of insurance a written binder issued by an authorized insurer or its agent if
the binder includes or is accompanied by: the name and address of the borrower; the name and address of the
lender as loss payee; a description of the insured real property; a provision that the binder may not be cancelled
within the term of the binder unless the lender and the insured borrower receive written notice of the cancel-
lation at least ten (10) days prior to the cancellation; except in the case of a renewal of a policy subsequent to
the closing of the loan, a paid receipt of the fun amOlmt of the applicable premium, and the amount of
insurance coverage.
Chapter 21 Title 25 Paragraph 2119
Applicable in Nevada
Any person who refuses to accept a binder which provides coverage of less than $1,000,000.00 when proof is
required: (A) Shall be fmed not more than $500.00, and (B) is liable to the party presenting the binder as proof
of insurance for actual damages sustained therefrom.
.A"COlm." . ..,~...
:.:....... ':. ". ':'.
. ... ...
::.' ...........::,. ...7.....::.
DEC-09-1998 09:24 HOLMES MURPHY
AccessAIG - Financial ratings
515 286 4493 P.02/04
Page 1 of1
The American International Companies are member companies of American International Group, Inc. (AIG).
AIG is the leading U.S.-based international Insurance organization and among the largest underwriters of
commercial and industrial insurance in the United States. Member Companies of the AIG domestic
intercompany pool hold the highest possible ratings from the major independent ratings services, A++
(Superior) from the A.M. Best Company for operating performance and financial strength, AAA (extremely
strong) from Standard & Poor'$. and Aaa (exceptional) from Moody's for financial strength.
.. ./bv .cgi ?BV _EngineID=caldfdemldmbejkcghecggkdnf6&BV _ Operation=Dyn _ SmartLinkRece 12/9/98