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EMPLOYEE BENEFITS CONSULTING GROUP EBCGCity o f South Miami INSURANCE BROKERAGE SERVICES RFP NO. SM- 2011 -08 -HR Employee Benefits Consulting Group INSURANCE BROKERAGE SERVICES RFP NO. SM- 2011 -08 -HR Employee Benefits Consulting Group 12555 Orange Drive Davie, Florida 33330 Phone (954) 473 -1034 x116 ebaynon(&ebeg.net Gene Baynon 7/8/2011 Employee Benefits Consulting Group TABLE OF CONTENTS L Letter of Interest IL Qualifications and Experience III. Forms IV. Cost Proposal V. Additional Information Employee Benefits Consulting Group Letter of Interest We appreciate the opportunity the City of South Miami has given us in regards to this Request For Proposal (RFP). Employee Benefits Consulting Group is prepared to assist the City of South Miami in managing healthcare costs while still maintaining the integrity of the benefits package. In this effort Employee Benefits Consulting Group acknowledges and commits to provide the following scope of services: On -Going Services: Expected deliverables include, but are not limited to: A. Monitor the programs' operations throughout the year to ensure that benefit providers are meeting all customer service requirements and standards. B. Provide on -going administrative support, as required, by acting as a liaison between the City and providers to assist with resolving claim disputes, contract administration and interpretations, and other issues. C. Provide dedicated personnel as a primary contact for managing the account relationship with the City. D. Meet with the City's Human Resources Director throughout the year as reasonably necessary (minimum is quarterly). E. Coordinate annual audits of City's benefit plans and associated vendors and prepare annual financial reports on the results of the completed plan year. F. Prepare and deliver any necessary reports to the City's Human Resources Director, including but not limited to, reports showing claims experience at intervals acceptable to the City. G. Provide advice and assistance in the review of the City employee health and medical benefits program on a continuing basis to ensure that those plans are in compliance with state /federal requirements and their adequacy of benefits with respect to other plans. H. Track, monitor and provide information on changes in, or any pending or new legislation in the applicable state and federal laws, as well as any employee benefit and funding trends that may affect the benefits program, to the City's Human Resources Director. I. Advise and assist the City as requested with: ■ Writing employee benefits plan modifications and /or new benefits plans and any required amendment approval process; } �� k�' ila'•e, Employee Benefits Consulting Group Submission of written reports and other documents as required by the state and /or federal government; ■ Coordination of the annual employee wellness fair. Development of an Employee Wellness Program (we have included a proposal from Ceridian in regards to life health assessment, outreach health coaching, and health management services. Please note the services provided by Ceridian are NOT included in our cost proposal to the City). I Perform special projects as requested by the City, including but no limited to: Development and assistance in the implementation of new insurance plans; Assistance with adjudication of specific claims as requested by the City; ■ Recommendation of alternative benefit designs or delivery systems as dictated by emerging plan costs for benefit practices. K. Ensure personnel availability for meetings, phone calls, and e -mail correspondence as required. L. Maintain confidentiality of City records and data in accordance applicable federal and state laws. M. Perform other related services on an "as- needed" basis. Renewal Year Services A. Using current health and medical benefit plans as benchmarks, research, design, and propose employee benefit plans for the City, as appropriate. B. Meet with the City as necessary to discuss benefit plan options and establish goals and objectives for the City's benefit programs. C. Provide analysis of current plans, including the review of past performance, with regard to renewal. D. Review additional available cost savings plan alternatives and creative funding options. E. Determine the appropriate employee and employer benefit contribution levels. 2 Employee Benefits Consulting Group F. Review and recommend annual contribution strategies for active participants and retirees. G. Provide City with information on what other municipalities of comparable size and location will be doing with their benefits in the upcoming years. H. Conduct renewal negotiations and develop appropriate information for management purposes. Upon City's request, coordinate a comprehensive "Request for Proposal" (RFP) process to identify potential high quality Benefit vendors, according to established City guidelines. The scope of the RFP may include but not be limited to: Medical, Dental, Vision, Basic Life, Voluntary Life, Accidental Death and Dismemberment, Short Term and Long Term Disability insurance providers. J. Act as lead negotiator and consultant to the City during benefit contract negotiations and renewals. K. Prepare and present a written analytical report of the proposals received including recommendation(s) and supporting documentation for recommendations. L. Review plan documents (including employee booklets) and master contracts before adoption and printing. M. Assist with planning and implementation of selected changes including transition from the current to new vendors, the renewal proposal, and other benefit changes. N. Assist with developing City employee benefit program communication materials. Coordinate the design, printing, and production of those materials, as edited and approved by the Human Resources Director. O. Advise and assist the Human Resources Director or designee with the review of contracts, plan documents, insurance policies and other documents for applicability, accuracy, consistency, and legal compliance. P. Assist City with the development of performance guarantees relating to vendors' performance of services to the City, and evaluation of the performance of vendors. Gene Baynon of Employee Benefits Consulting Group will be authorized to make representations for the firm. Gene is a Principal at Employee Benefits Consulting Group. He can be reached at (954) 473 -0146 x116 or e -mail ebayngn ebc .net. Employee Benefits Consulting Group PROPOSER'S QUALIFICATION STATEMENT Insurance Brokerage Services PROPOSER shall furnish the following information. Failure to comply with this requirement will render the Bid non - responsive and shall cause its rejection. Additional sheets shall be attached by the Proposer as required. PROPOSER'S Name and Principal Address: Bavnon Consultants, LLC (dba Employee Benefits Consulting Group) 12555 Oranee Drive Davie, FL 33330 Contact Person's Name and Title: PROPOSER'S Telephone and Fax Number: PROPOSER'S License Number: Gene Bavnon — Principal P (954) 473 -1034 x 116 F (954) 473 -0146 A016495 (Please attach certificate of competency and /or state registration.) PROPOSER'S Federal Identification Number: 65- 1083636 1. Number of years your organization has been in business, in this type of work: 10 ears. 2. Names and titles of all officers, partners or individuals doing business under trade name: Gene Baynon - Principal The business is an LLC (Limited Liability Corporation) 3. Describe your experience and services related to health management. This would include health risk assessments, wellness, health coaching, disease management, etc. On a semi - annual basis we have conducted Health Fairs at the City of South Miami. The following services have been provided at the Health Fairs: • Blood Pressure Tests • Glucose Screenings • Cholesterol Screenings • Body Mass Index • Flu Shots (provided once a year) We have included a Proposal from Ceridian in regards to life health assessment outreach /health coaching, and health management services Please note the services provided by Ceridian are NOT included in our cost proposal to the City. 4. Describe an example of a City for whom you have coordinated or provided these services. of South Miami 5. Have you ever failed to complete work awarded to you. If so, when, where, and why? We have never failed to complete work awarded to us. 6. How will you maintain confidentiality of the City's records and data (include in your discussion any security procedures for accessing, sending, and storing data that are currently in place)? All hard copy information is scanned into our computer system This information is Password and ID Protected. All hard copy information is destroyed immediately after being scanned. 7. Discuss your service approach and how you respond to City requests. Include what you consider non - urgent/routine requests and urgent requests. All telephone calls and e-mail requests are addressed within the same business day. We consider any request from the City to be urgent. 8. How do you measure client satisfaction? We measure client satisfaction on our retention rate. Our goal is to retain client relationships on a long term basis by managing each account in a timely and efficient manner. 9. Confirm that you serve as a consultant or broker, independently, and are not affiliated with any insurance company, third party administrative agency or provider network. We serve as a consultant and broker independently and are not affiliated with any insurance company, third party administrative agency or provider network. 10. Describe your experience in provider network development, recruitment and negotiation, and maintenance. When the City switched insurance companies in October 2004 Employee Benefits Consulting Group was given a list of 19 providers that were not in the AvMed HMO network. Employee Benefits Consulting Group was successful in getting 16 of these provides into the AvMed HMO network (84% success rate): 11. Outline your ability to provide expertise and experience in the areas of health benefit plan analysis and design. Employee Benefits Consulting Group moved the City to AvMed on October 1 2004. The City's average rate increase with AvMed over the last 6 years has been 6.7 %. During this same time period the average loss ratio has been 105.5%. On _a national level health care inflation has averaged 10% per Year. Here is a summary of our renewal negotiations with AvMed: Participating in the Provider Name AvMed HMO Network Kenneth Baer Yes Jamie Edelstein Yes Michael Feldman Yes Steven Fields Yes Jorge Fleites Yes Vicente Franco Yes Maria Garcia - Rivera Yes Carey Green Yes Michael Hoff Yes Nsidibe Ikpc No Diane Krieger Yes Rafael Llanso Yes Manuel Padron Yes Jorge Pastoriza Yes Lazaro Priegues No Neil Ronsenkranz Yes Efren Salinero Yes George Tershakovec Yes Vitor Weinman No 11. Outline your ability to provide expertise and experience in the areas of health benefit plan analysis and design. Employee Benefits Consulting Group moved the City to AvMed on October 1 2004. The City's average rate increase with AvMed over the last 6 years has been 6.7 %. During this same time period the average loss ratio has been 105.5%. On _a national level health care inflation has averaged 10% per Year. Here is a summary of our renewal negotiations with AvMed: 6 Employee Only Loss Ratio Plan Year Low HMO Rate % Increase (7a, Renewal 10/1/2005- 9/30/2006 $332.40 15.0% not applicable 10/1/2006- 9/30/2007 $344.79 3.7% 133.4% 10/1/2007- 9/30/2008 $347.57 .8% 138.0% 10/1/2008- 9/30/2009 $357.80 2.9% 84.4% 10/1/2009- 9/30/2010 $372.84 4.2% 77.4% 10/1/2010- 9/30/2011 $423.25 13.5% 94.3% Average 6.7% 105.5% 6 Prior to moving the City to AvMed on October 1 2004 the City was with 3 insurance companies in 3 years (other consultants /agents were involved). The average rate increase during this 3 year period was 37.3 %: Plan Year 10/1/2001- 9/30/2002 10/1/2002- 9/30/2003 10/1/2003- 9/30/2004 Insurance Company Blue Cross Blue Shield Neighborhood Health Cigna % Renewal Increase 40% 32% 40% 12. Explain in detail the types of analyses you have conducted relative to benefits analysis and design for a health plan with at least 100 employees. Please see our response to question #11. 13. Provide examples of communication materials developed and prepared by your organization for use in City's health benefit communication campaigns. Information is attached. 14.Are there any existing service provider relationships that may prevent you from acting independently and providing objective advice or guidance? (Examples, overrides, commission agreements, preferred contracts, pricing based on volume, etc.) There are no existing service Provider relationships that will prevent us from acting independently in providing objective advice or guidance. 15. List any subcontractors who will provide services under this Contract and the services they will provide. The foregoing list of subcontractor(s) may not be amended after award of the contract without the prior written approval of the Contract Administrator, to be designated by the City Manager, and whose approval shall not be unreasonably withheld. Ceridian is the only subcontractor included in our Proposal Ceridian would provide all services related to wellness (i.e onsite wellness /biometric screening life health assessment, outreach /health coaching, and health management services). 16. List and describe all bankruptcy petitions (voluntary or involuntary) which have been filed by or against the Proposer, its parent or subsidiaries or predecessor organizations during the past five (5) years. Include in the description the disposition of each such petition. There has been no bankruptcy petitions filed against our company. 17. Provide specific examples of a significant savings in the cost of benefits to the client that can be directly attributed to your past services. Please see our response to question #11. 18. List any companies your are affiliated with or have contractual arrangement with including insurance companies, third party administrators (claims or other administrative /record keeping services), provider networks, HR or benefits software vendors, etc. We are not affiliated with or have any contractual arrangement with insurance companies, third party administrators provider networks HR or benefits software vendors. 19. Describe your firm's ability to assist with Benefits Administration issues. Employee Benefits Consulting Group will continue to provide the following Benefit Administrative services: • COBRA administration • Retiree billing and premium collection • Eligibility administration (additions and deletions) • Day -to -day issues (claim resolution, prescription drug authorizations, provider issues, and etc.) 20. What distinguishes your firm from other consulting firms and why should the City select your firm for consulting needs? Over the last 6 years Employee Benefits Consulting Group has delivered favorable renewals to the City (6.7% average rate increase) during a time period when medical inflation has averaged 10% per year. During these renewal negotiations the average Medical Loss Ratio was 105.5 %. Prior to moving the City to AvMed on 10/1/2004 the City's average rate increase in the 3 preceding years was 37.3 %. Employee Benefits Consulting Group has a personal relationship with many employees at the City. Instead of calling the insurance companies we encourage employees to utilize our customer service department in resolving any issue. 21. What is the total number of employees that you have assigned, currently, to employees benefits counseling? Three employees will be assigned to the City of South Miami account: Gene Baynon — Principal Lisa Mullennix — Consulting Actuary Teresa Vergara — In -House Customer Service Representative 22. What is your corporate mission, vision and values, as well as your organization's philosophy towards providing benefits consulting services? Our philosophy at Employee Benefits Consulting Group is simple: Maintain a cutting edge approach to ensure we have the highest level of benefits at the lowest cost. Continue a superior level of customer service. Retain client relationships on a long term basis by managing each account in a timely and efficient manner. 23. Discuss your firm's quality assurance policies and procedures. How do you measure whether you are meeting these standards? What is the frequency of any such review? All financial documents, experience reports and renewal calculations are peer reviewed by our in -house consulting actuary and underwriter. Each of these individuals have at least 20 years of experience in the healthcare industry. 24. Detail your ability to monitor regulatory and legislative developments at both the state and federal level and how this will benefit the City and be communicated to the City. We receive legislative updates from several sources (insurance companies law firms, and ERISA compliance vendors) We will send this information to the City in an e-mail format. 25. List all claims, arbitrations, administrative hearings and lawsuits brought by or against the Proposer or its predecessor organizations(s) during the last (5) years. The list shall include case name, case, arbitration or hearing identification number, name of the court or tribunal, the name of the project over which the dispute arose; and a description of the subject matter of the dispute. There have been no claims, arbitrations administrative hearings or lawsuits brought by or against the Proposer or its predecessor organizations during the last 5 26. Describe all proceeding concerning business related offenses in which the Proposer, its principals or officers or predecessor organization(s) were defendants. There have been no business related offenses in which the Proposer, its principals or officers or predecessor organizations(s) were defendants. 27. Has the Proposer, its principals, officers or predecessor organization(s) been CONVICTED of a Public Entity Crime, debarred or suspended from bidding by any government during the last five (5) years? If so, provide details. The Proposer, its principals officers or predecessor or anization(s) have not been convicted of a Public Entity Crime debarred or suspended from bidding by any government during the last 5 years. The PROPOSER acknowledges and understands that the information contained in response to this Qualification Statement shall be relied upon by CITY in awarding the contract and such information is warranted by PROPOSER to be true. The discovery of any omission or misstatement that materially affects the PROPOSER'S qualifications to perform under the contract shall cause the CITY to reject the Bid, and if after the award, to cancel and terminate the award and /or contract. VERIFICATION PURSUANT TO SECTION 92.525(2), FLORIDA STATUTES Under penalties of perjury, I declare that I have read the foregoing Response to Qualification Statement and that the facts stated in it are true. DATED this 6th day of June, 2011. &-n,ploYee- i,Az! 6'eo t (Print Name of Proposer By (Sign Your Name on Line Above) � ✓yG���' �4y(no� (On Line Above, P nt or Type Name of Person Signing) FAILURE TO COMPLETE, SIGN, & RETURN THIS FORM MAY DISQUALIFY YOUR RESPONSE 10 REFERENCES Insurance Brokerage Services Please list three (3) governmental agency, or comparable corporate client, contract references for which you have done business within the past three (3) years: Agency Name: Address: City, State & Zip Code Telephone Number City of South Miami 6130 Sunset Drive South Miami, Florida 33143 (305 ) 668 -2515 Agency Name: Propulsion Technologies International LLC Address: 15301 SW 291h Street City, State & Zip Code Miramar, Florida 33027 Contact's Name Zafi Atanasova Telephone Number (786) 999 -0607 Agency Name: Lighthouse Point Yacht & Racquet Club Address: 2701 NE 42 "d Street City, State & Zip Code Contact's Name Telephone Number Lighthouse Point, Florida 33064 Patricia Vargas (954) 942 -7244 11 RESUMES Gene Baynon — Principal Gene has 20 years of experience in the group health insurance business. Gene has been involved in numerous aspects of the industry including account management, sales, and underwriting. Gene represents clients across a broad spectrum in the negotiation and ongoing management of their Employee Benefit Programs. These Benefit Programs include Life, Long Term Disability, Short Term Disability, Medical and Dental plans. His expertise in funding of these plans covers the entire range including traditional pooled rating, retention accounting, minimum premium and self - funding with or without specific and aggregate stop -loss protection. Gene graduated from the University of Iowa with a Bachelor in Business Administration. Lisa Mullennix — Consulting Actuary Lisa is a Member of the American Academy of Actuaries (MAAA) and is an Enrolled Actuary under ERISA. Lisa has 18 years of experience and has provided her expertise to employers, insurance advisors, healthcare providers, insurance companies, and government agencies. Lisa is a subject matter expert in the following areas: Financial management and modeling Consumer - driven health plans Mergers and acquisitions Cost projections and budget development Trend analysis Benefit design and evaluation Enrollment migration scenarios Contribution strategy Underwriting Rate setting Funding alternatives Reserves /IBNR Plan performance reporting Florida Statute 112.08 filing RFP consultation Renewal strategy and negotiation Utilization review Audit support Lisa graduated from the University of Illinois with a Bachelor of Science, Liberal Arts, and Sciences degree with a major in actuarial science. Teresa Vergara — In House Customer Service Representative Teresa has 10 years of experience in the group health insurance industry. She has a strong background in all aspects of employee benefits; including claims processing and resolution, COBRA, group Medical /Dental /Life /LTD /STD plans, and organizing employee enrollment meetings. Teresa is a graduate of Universidad del Norte, Colombia. 12 NON - COLLUSION AFFIDAVIT Insurance Brokerage Services STATE OF FLORIDA ) COUNTY OF MIAMI -DADE ) �ye.�E /non being first duly sworn, deposes and states that: (1) He /She /They is /are the p (Owner, Partner, Officer, Representative or Agent) of E —pwpE� J�ei^ /iS �nw f F n, Cyao��j the PROPOSER that has submitted the I attached BID; (2) He /She /They is /are fully informed with respect to the preparation and contents of the attached BID and of all pertinent circumstances concerning such BID; (3) Such BID is genuine and is not a collusive or sham BID; (4) Neither the said PROPOSER nor any of its officers, partners, owners, agents, representatives, employees or parties in interest, including this affiant, have in any way colluded, conspired, connived or agreed, directly or indirectly, with any other PROPOSER, firm, or person to submit a collusive or sham BID in connection with the Work for which the attached BID has been submitted; or to refrain from PROPOSING in connection with such Work; or have in any manner, directly or indirectly, sought by agreement or collusion, or communication, or conference with any PROPOSER, firm, or person to fix any overhead, profit, or cost elements of the BID or of any other PROPOSER, or to fix any overhead, profit, or cost elements of the BID Price or the BID Price of any other PROPOSER, or to secure through any collusion, conspiracy, connivance, or unlawful agreement any advantage against (Recipient), or any person interested in the proposed Work; (5) The price or prices quoted in the attached BID are fair and proper and are not tainted by any collusion, conspiracy, connivance, or unlawful agreement on the part of the PROPOSER or any other of its agents, representatives, owners, employees or parties of interest, including this affiant. Signed, sealed and delivered in the presence of: By' SignatuKe Print Name and Title Subscribed and sworn to before me this (p day of �y t 20 BRIAN M. KOBUS Notary Public (Signature) My COMMISSION # EE060764 M Commission Expires: I '•'_ EXPIRES January 31, 2015 y �prl0 LOl 5 Insurance Brokerage Services RFP No. SM- 2011 -09 -HR Page 20 of 25 SIGNATURE PAGE _ - ----- ------- _.... _.._._. -.__r. Insurance Brokera_ge Services The undersigned attests to his (her, their) authority to submit this Submittal and to bind the firm(s) herein named to perform as per agreement. Further, by signature, the undersigned attests to the following: I. The Proposer is financially solvent and sufficiently experienced and competent to perform all of the work required of the Proposer in the Contract; 2. The facts stated in the Proposer's response pursuant to Request for Proposal, instructions to Proposer and Specifications are true and correct in all respects; 3. The Proposer has read and complied with, and submits its proposal agreeing to all of the requirements, terms and conditions as set forth in the Request for Proposals. 4. The Proposer warrants all materials supplied by it are delivered to the CITY of South Miami, Florida, free from any security interest, and other lien, and that the Proposer is a lawful owner having the right to supply the same and will defend the conveyance to the CITY of South Miami, Florida, against all persons claiming the whole or any part thereof. 5. Proposer understands that if a team is short listed and selected to make oral presentations to the selection committee and /or CITY, only the team members who were involved in the preparation of the written submissions may participate in the oral presentations. Any changes to the team at the oral presentations may, at the sole discretion of the City, result in that Proposer's Bid disqualification. 6. The undersigned certifies that if the firm is selected by the City the firm will negotiate in good faith to establish a Contract. 7. Proposer understands that all information listed above may be verified by the City of South Miami and Proposer authorizes all entities or persons listed above to answer any and all questions. Proposer hereby indemnifies the City of South Miami and the persons and entitles listed above and holds them harmless from any claim arising from such investigation and verification process, including the dissemination of information pursuant thereto. Submitted on this 4 A day of 20 (If an individual, partnership, or non - incorporated organization) Witness: . Zic, Company: F..�/a)/EE r4F%�3 S✓ � Printed: -ere50. ro O_r% By: Title: �ys do µt gk Se CL'4� Print Name, Title:,�/�o., (If a corporation, affix seal) Company: r!...e/ayo,E BF- �Efi%S ��✓� -��f�� By: Attested by Secretary Print Name, Title: r^ e, Incorporated under the laws of the State of F7e,,-,�/a FAILURE TO COMPLETE. SIGN. & RETURN THIS FORM MAY DISQUALIFY YOUR RESPONSE Insurance Brokerage Services RFP No. SM- 2011- 09 -1-IR Page 21 of 25 CERTIFICATION OF AUTHORITY [To be completed and signed by a legal entity only. This Certification is not applicable to an STATE OF FLORIDA COUNTY OF MIAMI -DADE Corporation or Partnership LLP Joint Venture LLC I HEREBY CERTIFY that a meeting of the Board of Directors, Partners, and /or Principals (include DBA -Doing Business As, if applicable) of the following entity an organization existing under the laws of the State of held on cT✓/ bl" 20 /! and passed and adopted: wac the following resolution was duly "RESOLVED, that, as of the organization, be and is hereby authorized to execute the Proposal dated, 0 day of S :ZZ 20 J1 , to the City of South Miami and this organization and that my, execution thereof, attested by a Notary Public of the State, shall be the official, act and deed of this attestation" I further certify that said resolution is now in full force and effect. IN WITNESS WHEREOF, I have hereunto set my hand and affixed the official seal of the corporation this, day of 1-15 _,20// Print Name ov�e4 eq f/�o.� Signature r NOTARY PUBLIC: Notary Signaturee' =398-0153 M. KOBUS SEAL SION 9 EE050764 Personally known to me, or anuary 91, 2015 �� Personal identification: otarys.N,C:.' m 1, �.1Lt+tISt Type of Identification Produced FAILURE TO COMPLETE SIGN & RETURN THIS FORM MAY DISQUALIFY YOUR RESPONSE Insurance Brokerage Services RFP No. SM- 2011 -09 -HR Page 22 of 25 RFP INFORMATION FORM _... Insurance Broke rage Services I certify that any and all information contained in this RFP is true;' and I further certify 'that this RFP is made without prior understanding, agreement, or connections with any corporation, firm or person submitting a RFP for the same materials, supplies, equipment, or services and is in all respects fair and without collusion or fraud. I agree to abide by all terms and conditions of the RFP, and if the Proposer is a legal entity, I certify that I am authorized to sign for the Proposer. Please print the following and sign your name where indicated below: Firm's Name: 6 ++ pyele, 'RFAIEt! t3 e at v Principal Business Address: /7, 5'.5,5 2>_('Ve 7 kvi i 'C70 21 d,4 9'3330 Telephone: 6516 x{73 '"/03`f r //6 Fax: _(qsy) y73 —O /fib E -mail address: e-6gYne7 @ —e-be l. 41--7- Name Title:i /nu�sLL Signature of Authorized Representative: FAILURE TO COMPLETE SIGN. & RETURN THIS FORM MAY DISQUALIFY YOUR RESPONSE Insurance Brokerage Services RFP No. SM- 2011 -09 -HR Page 24 of 25 NO CONFLICT OF INTEREST CERTIFICATION Insurance Brokerage Services The undersigned, as Bidder /Proposer, declares that the only persons interested in this RFP are named herein; that no other person has any interest in this RFP or in the Contract to which this RFP pertains; that this response is made without connection or arrangement with any other person; and that this response is in every respect fair and made in good faith, without collusion or fraud. The Bidder /Proposer agrees that if this response /submission is accepted, to execute an appropriate CITY document for the purpose of establishing a formal contractual relationship between the Bidder /Proposer and the CITY, for the performance of all requirements to which the response /submission pertains. The Bidder /Proposer states that this response is based upon the documents identified by the following number: Bid /RFP No. The full -names and residences of persons and firms interested in the foregoing bid /proposal, as principals, are as follows: The Bidder /Proposer further certifies that this response /submission complies with Chapter 8(a) of the Code of Ordinance, City of South Miami, Florida, that, to the best of its knowledge and belief, no Commissioner, Mayor, or other officer or employee of the CITY has an interest directly or indirectly in the profits or emoluments of the Contract, job, work or service to which the response /submission pertains. Signed, sealed and delivered in the presence of: 0 Signat re Print Name and Title` Subscribed and sworn before me this LP day of 'SQ 20 E007Notary Public (Signature) My Commission Expires )398 -0153 FloAtlaNOlarySarvice.com FAILURE TO COMPLETE. SIGN & RETURN THIS FORM MAY DISQUALIFY YOUR RESPONSE Insurance Brokerage Services RFP No. SM- 2011 -09 -HR Page 25 of 25 CONE OF SILENCE AFFIDAVIT Insurance Brokerage Services The "Cone of Silence" specifically prohibits communication regarding RFP "S (bids) or any solicitation with the City of South Miami staff except by written means, with copy filed with the City Clerk. This takes effect upon advertisement for Request for Proposal and terminates when the City Manager makes his recommendation to the City Commission for the award. An exception is made for oral communication during pre - proposal conferences. In addition to any other penalties provided by law, violation of the Cone of Silence shall render any proposal disqualified. CITY OF SOUTH MIAMI DISCLOSURE AFFIDAVIT 6vie w $'• 4,017 being first duly sworn, state: The full legal name and business address* of the person or entity contracting or transacting business with the City of South Miami are: B�}�non L "onSv�fPntrS LG-G Ce�/2. CM�7✓o}/GrG S�nIE��S ��v+tu /� / l -7�, If the contract or business transaction is with a corporation, the full legal name and business address* shall be provided for each officer and director and each stockholder who holds directly or indirectly five percent (5%) or more of the stock in the corporation. If the contract or business transaction is with a partnership, the full legal name and business address* shall be provided for each partner. If the contract or business transaction is with a trust, the full legal name and address* shall be provided for each trustee and each beneficiary.. If the contract or business transaction is with an LLP or LLC, the full legal name and address* shall be provided for each member of the LLP or LLC. All such names and addresses are: The full legal names and business address* of any other individual (other) than subcontractors, material men, suppliers, laborers, or lenders who have, or will have, any interest (legal, equitable, beneficial or otherwise) in the contract or business transaction with the City of South Miami are: Insurance Brokerage Services RFP No. SM- 2011 -094IR Page 26 of 25 Notary Public Signed, sealed and delivered in the presence of: By: z�s ') 6 Signat _ Print Na a and Title Subscribed and sworn to before me this day of „Ly 20 `" ° BRIAN M. KOBUS .-R"— {Ll ., rn Notary Public (Signature) - - MY COMMISSION # EE060764 Y -?ray - EXPIRES January 31, 2015 My Commission Expires: "Cjgy` u� 31 +Zn1 S (407)3980153 FloritlaNOtanSeri FAILURE TO COMPLETE. SIGN & RETURN THIS FORM MAY DISOUALIFY YOUR RESPONSE Insurance Brokerage Services RFP No. SM- 2011 -09 -HR Page 27 of 25 COST PROPOSAL Employee Benefits Consulting Group is proposing a $20,000 annual consulting fee. The City of South Miami can pay this on a monthly basis @ $1,666.67 /month. Effective 10/1/2011 rates for the following plans will be net of commissions (i.e. there will be no agent commissions included in the rates): • Medical Insurance • Dental Insurance • Life /AD &D Insurance • Long Term Disability • Voluntary Life Insurance • Vision • Insurance Supplements In addition Employee Benefits Consulting Group will not accept any overrides or bonus /incentive payments from the insurance companies. FLORIDA DEPARTMENT OF INSURANCE EUGENE E SAYNON License Numb A016496 IS IICENSEDIOT E Health M; CIABS pInMICE'. 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U (A 5 G N O pp v Q. � _O E 2) Q- a) N C L N N Q v CU 0 Q }' O -0 riO O -Z ? Z O a"' O Un 0 Qll N N N E N C:3 N C Q C� G J L 4- L Q a- N N � a Q) C Q _O C 4� E (cu: O O v � Q d O d O -V} i/}. Q U m U L ro N U L V) U W L O O c L- 0 O E ai Q O O O Ln N t/} v U l6 O U ^N^' ^W W ^O C ^E W O M O CL L 0 'N O E w Q O O Ln N Ln i/} N U L N W O U L C CO C L Q O O ui n m 4- O F- • Z a 0 'a W v v 4- 'N O O U U ro L- 0 4� Q) U) i !k 2 v L m Q O O 0 a U O � � iff, / 11 y< \ }f \ c« .i \ A EMPLOYEE BENEFITS GUIDE ' Canyon Rock Development Corporation strives to provide employees with the most competitive benefit package in the industry. Our employees are our greatest resource and we take pride in being able to offer comprehensive and affordable m, benefits for all of our employees and their families including: • HMO Medical Plan provided by Blue Cross Blue Shield • PPO Medical Plan provided by Blue Cross Blue Shield • Prescription Benefits provided by Blue Cross Blue Shield • Dental PPO Plan provided by Aetna • Dental DMO Plan provided by Aetna • Vision Plan provided by VSP • Employee Assistance Program provided by Blue Cross • Flexible Spending Account provided by Aetna • Life and ADD provided by The Hartford • Optional Life provided by The Hartford • Short Term and Long Term Disability insurance provided by The Hartford • 401(k) Retirement Plan provided by the Principal Financial Group This booklet contains an overview of the valuable benefits package available to you at Canyon Rock. While every effort has been made to ensure that this booklet accurately reflects the provisions of the plans, only the official plan documents govern the operation of the plans and payment of benefits. If you have questions, please contact Human Resources. For complete benefit summaries and plan information, visit our benefits website. VISIT OUR EMPLOYEE BENEFITS WEBSITE: www.mybensite.com/canyon User Name: canyon Password: benefits for C010) G(t. IOd 1lfliat,orl plloa P ✓157 vrNwJgvbr Si tC.cOgVC allyo❑ GENERAL PLAN INFORMATION EMPLOYEE ELIGIBILITY All full -time Canyon Rock employees working 40 or more hours per week are eligible for benefits on the first of the month following date of hire. DEPENDENT ELIGIBILITY Unmarried dependents are covered through age 19. Unmarried college students are covered through age 25 if enrolled as a full time student (12 or more credit hours per semester) in an accredited institution. WHEN CAN 1 MAKE CHANGES? Open enrollment will occur once each calendar year. You may change your benefit elections during the open enrollment period. Once you have made your selection, you may not change benefit elections until the next open enrollment unless you have a qualifying change in employment or family status. "Qualifying Events' include: • Marriage, divorce or legal separation • You add a dependent child through birth, adoption or court - ordered change in custody • Death of a spouse or child • Your work schedule changes, affecting benefits, i.e. reduction or increase in hours, affecting eligibility • Your spouse begins or terminates employment, affecting benefit coverages • Your dependent loses eligibility for coverage • You and /or your spouse and dependents become eligible for COBRA If you experience a "qualifying event," you have 30 days to notify Human Resources and make any desired benefit changes. Otherwise, elections you make during open enrollment will remain In effect for the entire plan year. EMPLOYEE BI- WEEKLY RATES COVERAGE MEDICAL & RX ME LEVEL FPO Employee Only j $35.49 Employee + Spouse $75.53 Employee + Child(ren) $61.91 Employee + Family j $102.94 DICAL &RX HMO - $19.78 DENTAL, PPO $4.24 DENTAL,"I DMO $3.37 - VISIDC - Pm $1.88 $45.75 $7.27 $6.40 $3.58 $36.22 $8.18 $8.46 $3.75 $55.27 $12.54 $8.46 $5.75 For complete in hor III at'ion plea' ^e visit srww.i nyoeosi or cQrnkrnyon Customer Service: (800) 555 -1212 Canyon Rock Group Number: 1234567 BLUE CROSS BLUE SHIELD H M O PLAN . BENEFIT OVERVIEW IN NETWORK ONLY Annual deductible None Out of pocket expense limit $1,000 Individual / $3,000 Family Lifetime maximum Unlimited Coinsurance 100% MEDICAL •- ONLY Primary care physician office visit $30 copay Specialist care physician office visit $40 copay Lab and Radiology $30 copay 1" visit — $30 copay Maternity Subsequent visits — $0 copay Inpatient hospital care —$0 copay Free Standing Surgical Center $40 copay Surgery in an Outpatient Dept of a Hospital $100 copay Physical, Speech, Occupational; Respiratory & Cardiac Therapy $40 copay (max of 60 consecutive days from the onset of therapy for each occurrence) Family Planning (limitations and exclusions apply) 50% coinsurance Urgent Care Center $50 copay Emergency Room $100 copay Ambulance $0 copay Home Health Care $0 copay Hospice $0 copay Skilled Nursing Facility 20% coinsurance Prosthetic Devices & Durable Medical Equipment 20% coinsurance Mental Health & Substance Abuse INPATIENT $0 copay - max 60 days per year Mental Health & Substance Abuse OUTPATIENT Visits 1- 5: 1 20% coinsurance Visits 6 - 30; 35% coinsurance Visits 31 and Over: 50% coinsurance PRESCRIPTION NETWORK $15 generic Retail Pharmacy (up to 30 -day supply) $35 formulary $60 non - formulary — -- - $30 generic Mail Order (up to 90 -day supply) $70 formulary $120 non - formulary for romivte Inronnefion please visit www. invLehsitn.convcanyon BLUE CROSS BLUE SHIELD PPO PLAN PPO BENEFIT OVERVIEW IN NETWORK OUT OF NETWORK Annual deductible I None $300 Individual $900 Family Out of pocket expense limit None $3,000 Individual $6,000 Family Lifetime maximum Unlimited $1,000,000 Coinsurance 100% Member is responsible for 20% NETWORK IN OUT OF •- Primarycarephysicianofficevisit $20 copay 20% coinsurance + deductible Specialist care physician office visit $20 copay !20 % coinsurance +deductible Lab and Radiology $O copay 20% coinsurance + deductible 1" visit $20 copay Maternity Subsequent visits $0 copay 20% coinsurance + deductible Inpatient hospital care $ copay Free Standing Surgical Center $40 copay 20% coinsurance + deductible Surgery in an Outpatient Department of a Hospital $100 copay 50% coinsurance + deductible Physical, Speech, Occupational, Respiratory & Cardiac Therapy (max of 60 consecutive days from he onset $40 copay 20% coinsurance+ deductible of therapy for each occurrence) Famil99 Planning (limitations and exclusions apply) 20% coinsurance 50% coinsurance +deductible Urgent Care Center $20 copay 20% coinsurance + deductible Emergency Room $100 copay 20% coinsurance + deductible Ambulance $0 copay 20% coinsurance + deductible Home Health Care $20 copay 20% coinsurance + deductible Hospice $20 copay j 20% coinsurance + deductible Skilled Nursing Facility $20 copay j 20% coinsurance+ deductible Prosthetic Devices / Durable Medical Equipment ($2000maxa lies) $25 copay ;50 % coinsurance +deductible Mental Health & Substance Abuse INPATIENT $0 copay /max 60 days year 120 % coinsurance +deductible Mental Health & Substance Abuse OUTPATIENT Visits I -5: 20% coinsurance :20% coinsurance after deductible Visits 6 -30: 35% coinsurance 35% coinsurance after deductible Visits 31 and Over: 1 50% coinsurance 50% coinsurance after deductible _ • BENEFITS IN NETWORK Retail Pharmacy $10 generic $20 formulary (up to 30 -day supply) $45 non - formulary Mail Order $20 generic (up to 90 -day supply) $40 formulary $90 non - formulary For c:ngPiete information please visit www.myoensite.com /canyon Customer Service: (800) 555 -1212 Canyon Rock Group Number: 1234567 VCR IHL: Customer Service: (800) 555 -1212 Canyon Rock Group Number: 1234567 1�1 DENTAL P P O PLAN The Dental PPO plan allows you to visit any dental provider. When you use a network dentist, you will not be billed for any amount above the set fees negotiated by the insurance company and the dentist. If you go to an "Out of Network" provider, however, you may be responsible for any amounts above the Reasonable and Customary (R&C) charges for your area. This practice is often referred to as "Balance Billing:' While the benefits are technically the same regardless of whether you are using an in or out of network dentist, you will get more value if you stay in network. BENEFIT OVERVIEW IN NETWORK OUT OF NETWORK Annual Deductible $50 Individual $50 Individual $150 Family $150 Family Annual Maximum for Classes I, II & III $1,500 per member Preventive Care j • Oral examinations • Cleanings, including scaling and polishing 0% 0% • Fluoride No deductible No deductible • X -rays: bitewing and full mouth series Basic Services' • Root canal therapy; with X -rays and cultures • Amalgam (silver) fillings • Composite fillings (anterior teeth only) • Stainless steel crowns 20% 20% • Space maintainers After deductible After deductible • Uncomplicated extractions • Osseous surgery • Surgical removal of impacted tooth • General anesthesia • Denture repairs Major Services • Crowns, inlays and onlays 1 50% 50% • Full and partial dentures After deductible After deductible • Pontics Orthodontia Services 50% 50% Lifetime Orthodontia Maximum $1,500 per covered member for nlornahon OIQ2 Ov;sl erww nrvbi.us;;e.com /canyon DENTAL D M O PLAN The DMO plan works like an HMO. Each member of your family must select a Primary Care Dentist (PCD) from the list of participating Aetna DMO dentists. You may not use non - participating dentists. Your PCD will provide routine dental care and refer you to a specialist if needed. There are no deductibles, claim forms or maximums. Most diagnostic and preventive care is covered by Aetna at 100 %. You pay a fixed copayment for most other dental services that are significantly less than what you would pay without this plan. Discounts range from 30 - 60% off "retail" dental fees. Inside the Dental section of the employee benefits website, you will see a detailed Dental DMO schedule that will tell you EXACTLY what your copayment for any specific dental service will be. Although DMO provider networks tend to be smaller than Dental PPO networks, the out -of- pocket expenses to you are less than what you would pay under the Dental PPO. Before completing your enrollment form and selecting your PCD, we suggest calling the participating DMO providers' office and confirming that they are accepting new patients. BENEFIT OVERVIEW IN NETWORK ONLY Annual Deductible None Annual Maximum None Office Visit Copay $5 Orthodontia Lifetime Maximum Unlimited Preventive and Basic Care • Oral evaluations - • X Rays: bitewing and full mouth series 100% • Cleanings including scaling and polishing after office visit copay • Amalgam (silver filling) • Fluoride treatment (age limitations apply) Major Services • Root canals • Endodontics • Prosthodontics 50% • Crown and bridgework • Orthodontia i I'D. , ["ol01B1'l0w I If ;e "'; t eV W. ll' /llBi q;i,C,CGIIVC ]pyG❑ Customer Service: (800) 555 -1212 Canyon Rock Group Number. 1234567 Canyon Rock Cr Developmont Corporation V F Customer Service: (800) 555 -1212 Canyon Rock Group Number: 1234567 r! fi i VSP VISION PPO Canyon Rock offers a generous vision plan through your VSP PPO Vision Plan. Dollar for dollar you get the best value from your VSP benefit when you visit a VSP network doctor. If you decide not to see a VSP doctor, copays still apply. You'll also receive a lesser benefit and typically pay more out -of- pocket. You are required to pay the provider in full at the time of your appointment and submit a claim within 6 months to VSP for partial reimbursement. VISION SERVICE IN NETWORK OUT OF •- Eye Exams $25 copayment covers your eye Reimbursement Every 12 months- exam in full up to $45 $25 copay for materials applies Reimbursement as follows: up to: Lenses • Covered in full for single lenses • $45 for single lenses Every 12 months . Covered in full for bifocal lenses $65 for bifocal lenses • Covered in full for trifocal lenses • $85 for trifocal lenses Frames Frame of your choice covered up to $120.00. Plus, 20% off Reimbursement Every 24 months any out -of- pocket costs. up to $47 When you choose contacts instead of glasses, your $120.00 allowance applies to the cost of your contacts and the contact lens exam (fitting and evaluation). Contact Lenses Reimbursement Every 12 months This exam is in addition to your up to $105 vision exam to ensure proper fit of contacts. If you choose contact lenses you will be eligible for a frame 12 months from the date the contact lenses were obtained. EXTRA DISCOUNTS AND SAVINGS In addition an employee who visits an in- network doctor will be entitled to: • Laser vision correction discounts • Up to 20% savings on lens extras such as scratch resistant and anti - reflective coatings and progressives • 20% off additional prescription glasses and sunglasses • 15 °% off cost of contact lens exam (fitting and evaluation) For cmnpiere In ornwtUon please visit www . i nvbenstec orn /canyon EMPLOYEE ASSISTANCE PLAN Everyone occasionally experiences serious personal problems. Locating the right assistance is at times as confusing as the problem itself. The company provides a counseling resource that quickly and professionally assists you in handling problems affecting your personal or work life. Why allow problems to continue unresolved? Your EAP is available to help you. YOUR EAP IS CONFIDENTIAL Your concerns remain private with the EAP therapist. If your supervisor refers you to the EAP due to job performance problems, the EAP will, with your permission, inform your supervisor that you are, or are not, following EAP recommendations. The EAP will not share personal or private information with the company. When you call the Employee Assistance Program (EAP) number, you will be connected to a counselor who will help you clarify your problem, identify options, offer support and professional guidance, and help you develop an action plan. When needed, you will be offered an in- person appointment in addition to the telephone consultation. The company is providing the EAP as a free benefit to you and your family. The EAP is not a full treatment program. In some cases an interview with the EAP counselor will result in a referral to local counseling services. These other counseling services are reimbursed in accordance with your existing medical benefits plan. WHAT TYPES OF ISSUES CAN MY EAP ASSIST ME WITH? • Marital conflict • Relationship concerns • Parent and child issues • Budget and debt problems • Stress and anxiety • Depression • Legal concerns • Child care • Education and college planning • Eldercare • Substance abuse • job stress • Financial issues • Work and life balance `u, coinp. r.o; nizhant r i,ovsit ww!nybrto onn<anyon PLAN Customer Service: (800) 555 -1212 Canyon Rock Group Number: 1234567 ,err..,. ��., t ��.��• ' Canyon Rock p Development Corporation V FLEXIBLE SPENDING ACCOUNT To help you save money on health care and dependent care costs, Canyon Rock is happy to offer our employees Flexible Spending Accounts through Aetna. The purpose of a Flexible Spending Account is to allow you to set money aside on a pre -tax basis to cover expenses that are riot otherwise covered under a traditional medical, dental or vision plan. Customer Service: (800) 555 -1212 THERE ARE TWO TYPES OF FLEXIBLE SPENDING ACCOUNTS Canyon Rock Group AVAILABLE TO YOU: Number: 1234567 ': • Dependent Care Reimbursement Account • Health Care Reimbursement Account HOW DOES AN FSA WORK? • At the beginning of each plan year, employees elect the amount they will use pre -tax for dependent care and healthcare expenses to be deducted in equal increments from their paycheck. h- The monies are held in a separate account for each employee until the employee submits an eligible expense claim. Once a claim is submitted to Aetna, they will reimburse you for the expense. You save approximately $30 on every dollar you spend through your FSA! a IMPORTANT NOTES x x +{ a 1) The FSA plan year runs from January 11' — December 31 ". 2) You have until March 3151 to submit claims for expenses incurred during Try I8r ary gVet�tlw(t of � the previous plan year. 3) Your Dependent Care annual maximum is $5,000. �IoFo.�l, et d9t$tl§ a 4) Your Health Care annual maximum is $3,000. refeM t4 fit@ S,Uittriery 5) Unused funds will be forfeited (i.e. "use it or lose it "). Be sure that you rt�isn D6 @t3Fipfloflr(SpCS), carefully plan your expenses so that you do not over - budget. 6) Remember that you may sign up for the direct deposit option. - 7) You will be issued a new credit card by Aetna. GUIDE Visit our website for complete FSA information Be sure to review the employee benefits website at www.mybensite.com /canyon. You will find helpful resources such as an FSA calculator, extensive lists 4 of eligible and ineligible expenses, forms, provider links and frequently asked questions. Hn G�nq]lete In fOnliah Un plf d.aP 4siL ww W nlyb @nSitC.GGm /canyon DEPENDENT CARE REIMBURSEMENT ACCOUNT The dependent care account is specifically for: • Child care expenses for children up to age 13. • Adult day care expenses for dependents who you claim on your income taxes, that are mentally or physically unable to care for themselves. IMPORTANT NOTES FOR DEPENDENT CARE ACCOUNTS 1) Dependent care benefits elected under an FSA plan offset the federal tax credit for dependent care allowable on your federal tax return. 2) Both spouses must work or attend school full time to take advantage of this benefit. 3) Only the amount that has been deducted year to date from your paycheck can be submitted for expense reimbursement. HEALTH CARE REIMBURSEMENT ACCOUNT Health Care Spending Accounts offer employees the opportunity to pay for eligible out -of- pocket medical costs with pre -tax dollars. Our benefits website contains a complete list of eligible and ineligible expenses, however the below information is a sample of some popular expense categories. COVERED EXPENSES: • Office visit and prescription copays • Deductibles • Coinsurance • Insulin and diabetic supplies • Braces and other orthodontic expenses • Weight loss programs prescribed to treat a medical condition • Acupuncture • Chiropractic care • Infertility treatments • Hearing aids • Orthopedic shoes • Lasik / laser eye surgery • Medical equipment (wheelchairs, crutches, braces) • Adoption expenses • Ambulance expenses • Over the counter drugs for the treatment of injury or illness • Breast pumps • Prosthetics and artificial limbs EXPENSES NOT COVERED: • Healthcare premium contributions • COBRA premiums • Prescription drugs for cosmetic purposes • Vitamins • Teeth bleaching / bonding • Physical treatments or personal trainers for non - medical conditions • Cosmetic surgery for non - medical conditions • Electrolysis or other types of hair removal • Dermatology work for non - medical conditions • Cost of diet foods or special nutritional supplements • Gym or athletic club memberships • DNA testing • Domestic partners • Doula / birthing coach expenses • Far piercing • Maternity clothes rof 1JI O;J! , _) ❑ldi =On p If, of ,S,i ,Jw Y,.i rly v P,.bSdf CaNcanvon Exatnplee of eligible : Dependent Cara ed , Customer Service: (800) 555 -1212 Canyon Rock Group Number: 1234567 Canyon Rock �/� Development Corporation V LIFE, AD &D and OPTIONAL LIFE BENEFITS Canyon Rock Development Corporation offers a generous life insurance package. The company pays 100% of the premium for your Basic Term Life and Accidental Death and Dismemberment (AD &D) benefits. The information below provides an overview of benefits. Please see the employee benefits website for complete details and a Summary Plan Description. BASIC TERM LIFE INSURANCE BENEFIT Two times your Basic Annual Earnings (rounded to the next highest $1,000) to a Customer Service: maximum of $100,000. Benefit reduces to 35 °% at age 65 and is reduced to 50% at (800) 555 -1212 age 70. Canyon Rock Group AD&D BENEFITS Number: 1234567 If death is the result of an accident, the Beneficiary will receive an additional amount equal to your Life Insurance in force. If you are dismembered (such as loss of sight in an eye, loss of a hand, foot, limb, hearing, speech, etc.), benefits will be paid to you as a percentage of the basic life amount. This Is an overview of benefits. For complete details, refer to the Summery Plan Description (SPD). 11' BENEFITS GUIDE OPTIONAL LIFE FOR EMPLOYEES, SPOUSES AND CHILDREN Canyon Rock Development Corporation offers additional term life insurance available at low group rates. Premiums are 100% employee paid and are automatically de- ducted from your paycheck on a post -tax basis. In order to purchase life insurance on your spouse or children, you MUST purchase voluntary life insurance on yourself. Employee j Increments of $10,000 up to a maximum of $250,000 Spouse i Up to 50% of your benefit amount in increments of $5,000 up to a maximum of $50,000 Child $5,000 or $10,000 EVIDENCE OF INSURABILITY If you enroll in the Optional Life Insurance Program when you initially become eligible, you will not have to provide evidence of insurability unless you purchase more than $100,000 of coverage. If you elect not to purchase supplemental life insurance when you initially become eligible and later decide to take advantage of this benefit, you will be required to provide evidence of insurability regardless of the amount of coverage you elect. for nplege InhmnaI (,ri plr ase v sit wwv uHbr i.site.com /canyon DISABILITY BENEFITS Your family can count on your income while you are healthy and employed, but it is important to plan for their financial security in the event that you become disabled and unable to work. Canyon Rock offers a generous Long Term Disability plan to all full time employees working 30+ hours per week. Short Term Disability benefits are offered on a voluntary basis at low group rates for those employees with less than two years of service. VOLUNTARY SHORT TERM DISABILITY BENEFITS: • Benefits are all 100% employee paid on a post -tax basis. • This benefit will pay 60% of your basic weekly earnings up to a maximum benefit of $500 per week minus any income that is listed in the Benefit Reductions provisions. • Benefits begin on the 8th day for an accident and or the 8th day for sickness and /or illness. • In order to receive benefits, the Short Term Disability Claim Form that can be found on our website must be completed by you, your doctor and the company. • Short Term Disability benefits are paid on a weekly basis. • If you are still disabled and incapable of working after 12 weeks, your Long Term Disability benefits, if approved, will begin. • Late enrollees require medical underwriting. LONG TERM DISABILITY BENEFITS (100% EMPLOYER PAID) • A 90 day elimination period applies before Long Term Disability benefits begin. • Long Term Disability benefits will pay 60% of your monthly salary. • The maximum monthly benefit is $10,000. • Benefits will be paid for the duration of the disability. • Benefit reductions will occur at age 65. • Long Term Disability benefits are paid on a monthly basis. • Your benefit will be reduced by amounts you receive from Social Security, an employer sponsored retirement plan and other group disability benefits. • Disabilities primarily based on self - reported symptoms or disabilities due to mental illness have a limited pay period of up to 24 months unless you remain hospital confined at the end of the 24 -month period. Ior some.e n romeWor puase msit www'I IIV ; t¢.( Q rill( anyon uwiiiiiiiI■ ■ ■ M; Customer Service: (800) 555 -1212 Canyon Rock Group Number: 1234567 _Ww� 1�� 401K RETIREMENT PLAN RETIREMENT f Canyon Rock Development Corporation is pleased to provide the LAN' most beneficial personal savings and retirement program available; _., a tax- deferred 401(k) Profit Sharing Plan! Customer Service: Vesting % 20% vested ELIGIBILITY (800) 555 -1212 3r11 year You are eligible to join the plan if you are age 21 or older and work 40 or more 41" year 80% vested hours per week. You may join the plan on the first day of the month following 30 Canyon Rock Group -r days of active employment Number: 1234567 VESTING Employee contributions are always 100% vested. Any money you roll over into the Plan is always 100% vested. You are vested in the discretionary profit sharing according to your years of service with the Company according to the following schedule: Years of Service Vyear Vesting % 20% vested 20" year 40% vested 3r11 year 60% vested 41" year 80% vested 5`1 year 100% vested COMPANY CONTRIBUTIONS t F`, The company will match 50% of the first 5 %. LOANS You may borrow up to 50% of their vested account balances as long as you have a vested Plan account balance. The minimum loan amount is $1,000 and the maximum loan amount is $50,000. You may have a maximum of 2 outstanding loans at any time. There is a one time setup fee of a $150 which will be paid from your account prior to obtaining a loan from the Plan. WITHDRAWALS If you leave for any reason (including retirement after age 65), you may withdraw your vested account balance. While you are still employed you may make limited 3 withdrawals from your account if you experience a severe financial hardship (as defined by the IRS). AUTOMATIC ENROLLMENT NOTIFICATION This le an overview of While your contribution is automatic, you have the option at any time to direct your benefits, contributions to other investment options available through your Plan. You also have the option to change your contribution rate, including declining to make any For complete details, contributions (contact Wachovia at 1 -800- 377 - 9188). refer to the Summary Plan Descflptlon (SPO) For romplete Intorniabon please visit svww.i nvUensitrd. utnv<:anyon We encourage all of our employees and their families to become familiar with and use the resources offered on the Canyon Rock benefits website. If you do riot find what you need, please use the following contact informa- tion to speak directly with a benefits professional that can better serve you VISIT OUR EMPLOYEE BENEFITS WEBSITE: www.mybensite-com/canyon User Name: canyon Password: benefits Customer Service: (800) 555 -1212 Canyon Rock Group Number: 1234567 This Is an overview of benefits. For complete details, refer to the Summary Plan Description (SPD). F(1 1 l;onn)'zt2 10 fn[I1"I ti00 P f 13e VIS,t WW W. i ny bel lSi te. c 0? 11/CB l Lyon k 14 it Caporatlop i ?i r CARRIER COMPANY CUSTOMER INFORMATIONr Human Resources Canyon Rock I 1 Benefits Department Phone: (407) 909 -1136 E -mail: info@wbdcorp.com Medical: HMO and PPO Blue Cross Blue Shield Group Number: 1234567 Customer Service Number: (800) 555 -1212 Website: www.bcbs.com Prescription Blue Cross Blue Shield Group Number: 1234567 Customer Service Number: (800) 555 -1212 Website: www.bcbs.com Dental: PPO and DMO Aetna j Group Number: 1234567 Customer Service Number: (800) 555 -1212 Website: www.aetna.com Vision VSP Group Number: 1234567 Customer Service Number: (800) 555 -1212 Website: www.vsp.com Employee Assistance Plan Blue Cross Blue Shield Group Number: 1234567 Customer Service Number: (800) 555 -1212 ii Website: www.eap.com FSA Aetna Group Number: 1234567 Customer Service Number: (800) 555 -1212 Website: www.aetna.com Life, AD &D and Group Number: 1234567 Voluntary Life The H e artford Customer Service Number: (800) 555 -1212 Website: www.thehartford.com Voluntary Short Term Disability Group Number: 1234567 The Hartford Customer Service Number: (800) 555 -1212 Website: www.thehartford.com Long Term Disability Group Number: 1234567 The Hartford ! Customer Service Number: (800) 555 -1212 Website: www.thehartford.com 401(k) Retirement Plan Principal Financial Group Group Number: 1234567 Customer Service Number: (800) 555 -1212 I Website: www.pfc.com This Is an overview of benefits. For complete details, refer to the Summary Plan Description (SPD). F(1 1 l;onn)'zt2 10 fn[I1"I ti00 P f 13e VIS,t WW W. i ny bel lSi te. c 0? 11/CB l Lyon k 14 it Caporatlop i ?i QUESTIONS? Visit the Canyon Rock Employee Benefits Website: www.mybensite.com /canyon For more information, please call: (800)119 -8952 Ww "I ut s 4 1 EMPLOYEE BENEFITS GUIDE This Employee Benefits Guide is a SAMPLE of copyrighted material. All rights are reserved by Web Benefits Design Corporation, No part of this document or the related tiles maybe reproduced or transmitted in any form, by any means, (electronic, photocopying, recording, or otherwise) without the prior written permission of Web Benefits Design. Any reproduction of this brochure in part or in its entirety without the prior written consent will be considered a direct violation of copyright laws and may be subject to prosecution. is J'. Ww "I ut s 4 1 EMPLOYEE BENEFITS GUIDE This Employee Benefits Guide is a SAMPLE of copyrighted material. All rights are reserved by Web Benefits Design Corporation, No part of this document or the related tiles maybe reproduced or transmitted in any form, by any means, (electronic, photocopying, recording, or otherwise) without the prior written permission of Web Benefits Design. Any reproduction of this brochure in part or in its entirety without the prior written consent will be considered a direct violation of copyright laws and may be subject to prosecution.