HomeMy WebLinkAboutSharp Health Plan; 1997-01-08;SHARP
HEALTH PLAN
GROUP AGREEMENT F-OR EMPLOYER GROUPS >50
EXECUTION PAGE
A.
.
EMPLOYER GROUP INFORMATION SUMMARY
1. Group Name and Address Citv of Carlsbad
1200 Carlsbad VillaPe Dr.. Carlsbad. CA 92008
2. Group Number 20500
3. Initial Term of this Agreement 01 101 /97 through 12/31 /97
4. Employer Contact Person/Telephone Number Julie Clark / 434-2955
5. Annual Open Enrollment Period 11/12/96 through 12/13/96
6.
7.
Coverage Effective Date After Open Enrollment
First Date of Benefit Year (calendar year)
Employee Data and Eligibility Information
a. Total Number Employees
b. Total Number Eligible Employees
C. Eligible Employee Definition
d. Eligible Dependents
e. Coverage Effective
f. Preexisting condition waiting period:
01 /01/97
01 /01/97
490
390
Permanent/Minimum 30 hour work week.
Resides or works within San Diego County.
Spouse, children through age 18, full-time
students ages 19 through 24.
New Hires: Date of hire.
Rehires: Date of rehire.
None.
8.
9.
10.
Termination Date: End of month for which ureuavment fees are made.
Plan Account Representative/Telephone Number Rick Leon / 637-6558
Plan Group Service Representative/Telephone Number Audrev Mueller / 637-6577
Standard Industry Code 9100
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11. Broker/Consultant:
Name
Address
Telephone Number
Towers Perrin
1925 Centurv Park East #1500, Los Anneles. CA 90067
(310) 551-5742
License Number N/A
Tax ID Number N/A
B. PLAN CONTRACT TYPE(S) AND PREPAYMENT FEES
Employer Contribution (Semi-Monthly):
;.I ::.y : :. : : .j:. : : ; ,: .; :..: +.:..:. :.. ..:y: ::‘;:.:;:::.::::& :::+.; ; :.:::: :;m: ,I.. :::::,::::::::-::::i:.: j ..,.: .: .::-: : :. : ::. ‘. : :.:: .:.:: ::.: :::: : .‘), :: j;, ../ ..::::., .A:: :.,: :::::: :: :::;. $ . . :‘:::‘:“.A.. ,:.:. . . : :..: ,:.:. : ,. .:.:::.:.:g::: :... : :.: : . . : .: .:.. :.j:..: . . . . . . .:. . . . . . . .\. . . ..j: .;:j::. .::.:.+j, :: j,.; j ,/, 3.; i. .:. : :: j :“::‘:‘j : .,.,: ,:. : :.>.:. j .,..:..: :.:.:,:... . .. .. ,:. .: :.::. :..:. . . . ! ;:: ~~.i:~~~~i~~~l~~~~p <+f$ ;‘:~:~~~!~~~~I~~~ : :,.,:: .:.,; : ,: :.:..::.: .:. : . . . . j::::,i:\: I::,. :, .:.: : . . . . . : :. : .:’ . . . . . :.j .: ,., ,. ., _ . . . . . . . . . . . . . ., . . . . . . . . . . . . . . $3 -E~p~~:~~~~‘~~.~~. : ‘$ ’ ~:is:i~~lF~~~:~~~~; i, ; : ;.;i ,. . . . . . . . . ,. .,. ,. . . ,. . . . .,. ./,. .,. ,.
FIRE $58.39 $116.79 $165.24
GENERAL $68.50 $133.39 $183.64
MANAGEMENT $65.61 $124.01 $165.28
Participation of Eligible Employees: 10 Subscribers Enrolled
.: ,;:: :, : : ,: :. : ; : : : : .: . . : : : ..: :.: .: . . :. :. ..:.:.::..:..: ,: .:’ . . :...:.::,.: ,: : ,:: .:.. :;:. . . . . . 1. :.::. j
.: : : ,. 1, : : :.. .::. ::.:. -::.:::::::::/;:.::.:.:.:.: I.( :.:.: .: :.: :, :,,: : : :,-i.::i:i:,::::: :......,. . I.... . . . . . . . . :. ::........: . . .:::.,/ ,.: :,.: . . . . . . . . .
.........:.:.:.: ..: :Y’-:?:.: :‘:‘.‘.‘.‘. .:.:: :. :I:.:.::.
: :‘: ::‘( ,. ,j,y ;:;:g+: .. ~:.j::.jj:ji:.lilll:i.i::: :..,::. ::.:.. :.;,i::
: : : j jj 5: :: ;g& :~~~~~~~~i.~~
yiii:j radii 2.;;:
3: : : ::~~~~~~~~~ .a... . . . . . . . . . . . . . . . . . . . . . . . . . j j:: : ;:j ,: : :, ;,,j:: 1::;. :. ) ,.,.,.i,.,.,.,.,.,. .,.,.,.,.,. ., . . .> 3:x :: ‘:::.E .: .: : .: .::::. -. . . . . . . . . . . . . .,.,.,.,.,.,., .: ~.:.~‘::::i:..ii:i:~~pie:i;i”:::i:::.’:’:I ..;ii:iiiB~~~:~:~:~ Employee Employee Employee
; j: j :: ;; y; ,; I:.. :... .I . . . . .._ :... ;. ..:...:.. . . . . . . . . hlY Pius One & Family
Medical A $98.23 $1%.47 $294.70
Prescription Drug 04 $9.24 $18.48 $27.72
Vision A0 $.SO $1.60 $2.40
Mental Health/ $5.51 $11.02 $16.53
Chemical Dependency Cl
TOTAL $113.78 $227.57 $341.35
COBRA RATES (when applicable):
X Premium Billed (Rates as stated above)
Direct Billed (Add 2% administration fee to above stated rates)
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By: *
Title:
Date:
By:
Title:
C. AGREEMENT EXECUTION
An application is hereby made by the undersigned Employer Group for participation in
Sharp Health Plan’s health care service plan in accordance with the provisions of the Sharp Health Plan
Group Agreement, the provisions of which are to be made available to all Eligible Employees as defined
above and their eligible Dependents desiring coverage thereunder. No enrollment or benefits thereon will
accrue until this Execution Page of the Group Agreement is completed, signed and returned to Sharp Health
Plan. By signing hereunder, the Employer Group acknowledges receipt of the Sharp Health Plan Group
Agreement.
IN WITNESS WHEREOF, the parties have duly executed this Group Agreement on the
day and year first above written.
January 7, 1997
Mayor
Company: Citv of Carlsbad
Date: January 8, 1997
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’ - ‘RITE IT - DON’T SAY ‘T!
To File
From Isabelle Paulsen
Date January 9
0 Reply Wanted
ONo Reply Necessary
1997
On this date, Julie Clark, Human Resources, received an original agreement. to the consultant. Julie stated she would provide a copy