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Home My WebLink About2008 Blue Cross Blue Shield Ins. %i ®~ . J of Florida MlndepeMnG Uoenmad Ms Blue Cost and Blur ShklOAatodatbn COBRA COMPLIANCE (CHECK APPROPRIATE BOX( ^ Our company employed 20 or more full and/or part-time employees* during the previous calendar year and is subject to federal COBRA. All full and part- time common law employees of an employer are considered in determining COBRA compliance. All full time employees are counted as one employee and each part-time employee is counted as a fraction of an employee. ^ Our company employed fewer than 20 full and/or part-time employees* during the previous calendar year and is subject to the Florida Health Insurance Coverage Continuation Act ("FHICCA'~. All full and part-time common law employees of an employer are considered in determining COBRA compliance. All full time employees are counted as one employee and each part-time employee is counted as a fraction of an employee. * For COBRA and FHICCA purposes, self-employed individuals, independent contractors and non-employee directors are not counted. MEDICARE SECONDARY PAYER COMPLIANCE (CHECK APPROPRIATE BOX) Multiple employer plan: a plan sponsored by more than one employer. Multi-employer plan: a plan jointly sponsored by more than one employers and unions. If you are a single employer plan: ^ Yes ^ No Our company employed 20 or more employees** each working day in 20 or more calendar weeks during the current or preceding calendar year. If you are a single employer, multiple employer or amultiple-employer plan: ^ Yes ^ No Our company employed 100 or more employees'* on 50 percent or more of the business days during the preceding calendar year. If you are a multiple employer or a multi-employer plan: ^ Yes ^ No All employers in our Group Health Plan (GHP) employed 20 or more employees** for 20 or more weeks in either the current or preceding calendar year. ^ Yes ^ No At least one of the employers in our GHP employed 20 or more employees*" for 20 or more weeks in either the current or preceding calendar year. ^ Yes ^ No All employers in our GHP employed fewer than 20 employees** for 20 or more weeks in either the current or preceding calendar year. ** "Fmnlnvees" includes all full and/or part time employee enera n orm~tron 4 1. Group Name CITY OF SEBASTIAN 2. Group Number 94085 3. Group Sales Rep/Agent THE GEHRING GROUP - 2913 - KURT GEHRING 4. Effective Date 10/01/2009 5. Employer Contribution Toward Employees Premium (must be at least 100% for 1-3, 50% for 4-50 and 75% for 51+) 100% II. Recap of Employee Participation 1. TOTAL EMPLOYEES ON PAYROLL => 183 2. TOTAL COBRA CONTINUANTS => 3. TOTAL INELIGIBLE EMPLOYEES Total ofA+B+C => A. Total Part Time Employee(s) _> B. Total New Employee(s) (in Waiting Period) _> C. Total Employee(s) Other => 4. TOTAL ELIGIBLE EMPLOYEES (DETERMINES GROUP SIZE & PRODUCT) 1+2 Minus 3 => D. Total Employees with Other Coverage => E. Other 5. TOTAL ELIGIBLE FOR PARTICIPATION 4 Minus D + E _> F. Total Refusals (eligible employees not taking the coverage) _> 6. TOTAL ENROLLED 5 Minus F => 7. EMPLOYEE PARTICIPATION (100% 1-3, 70% 4-50, 75% 51+ is REQUIRED) 6 Divided by 5 => Employers must have an application completed for all employees, even those who are not taking the health coverage, and submit those applications to Blue Cross and Blue Shield of Florida, Inc. and/or Health Options, Inc. It is recommended that the employer also retain a copy of all applications. I certify that the above information is correct to the best of my knowledge. I understand that this information will be used to determine my company's compliance with Blue Cross and Blue Shield of Florida, Inc an/or Health Options, Inc. eligibility and Underwriting Guidelines, as well as the applicability of State and Federal laws relating to my company and plan. Blue Cross and Blue Shield of Florida, Inc. and/or Health Options, Inc. reserves the right to request a UCT-6 or other documentation as evidence of business activity at any time and from time to time in order to validate my compliance with eligibility and Underwriting Guidelines, as well as validate the applicability of State and Federal Laws. Any pers wh owingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or mislea inf on is guilty of a felony of the third degree. City Manager 08/27/09 G up Officer's Signature Title Date B1ueCrose BlueShield .,. v of F'lorlda ENROLLMENT SUMMARY • ~ Health Options. d mno.... ra.pnu.K usa.e. am. ew oos .e a,,. sire ama. COBRA COMPLIANCE (CHECK APPROPRIATE BOX) ^ Our company employed 20 or more full and/or part-time employees* during the previous calendar year and is subject to federal COBRA. All full and part-time cotnmon law employees of an employer are considered in determining COBRA compliance. All full time employees are counted as one employee and each pan-time employee is counted as a fraction of an employee. ^ Our company employed fewer than 20 full and/or part-time employees* during the previous calendar year and is subject to the Florida Health Insurance Coveraee Continuation Act ("FHICCA"). All full and part-time common law employees of an employer are considered in determining COBRA compliance. All full time employees are counted as one employee and each part-time employee is counted as a fraction of an employee. * For COBRA and FHICCA purposes, self-employed individuals, independent contractors and non-employee directors are not counted. MEDICARE SECONDARY PAYER COMPLIANCE (CHECK APPROPRIATE BOX) Multiple employer plan: a plan sponsored by more than one employer. Multi-employer plan: a plan jointh sponsored ny employers and unions. If you are a single employer plan: ^ Yes ^ No Our company employed 20 or more employees** each working day in 20 or more calendar weeks (does not have to be consecutive weeks) during the current or preceding calendar year. If you are a single employer, multiple employer or amulti-employer plan: ^ Yes ^ No Our company employed 100 or more employees** on 50 percent or more of the business days during the preceding calendar year. If you are a multiple employer or amulti-employer plan: ^ Yes ^ No All employers in our Group Health Plan (GHP) employed 20 or more employees** for 20 or more consecutive weeks in either the current or preceding calendar year. ^ Yes ^ No At least one of the employers in our GHP employed 20 or more employees** for 20 or more consecutive weeks in either the current or preceding calendar year. ^ Yes ^ No All employers in our GHP employed fewer than 20 employees** for 20 or more consecutive weeks in either the current or preceding calendar year. ** "Employees" includes all full and/or part time employee I. Cenei~al Information'; ~ ,' .. 1. Group Name CITY OF SEBASTIAN 2. Group Number 940135 ~3. Group Sales Rep/Agent S dne Hod a 4. Effective Date 10/1/2008 5. Employer Contribution Toward Employees Premium (must be at least 50% for 1-50, 75% for 51+) 100% H. Recap. of Employee Participation , 1. TOTAL EMPLOYEES ON PAYROLL -> 175 2. TOTAL COBRA CONTINUANTS => 0 3. TOTAL INELIGIBLE EMPLOYEES Total of A+B+C => 15 A. Total Part Time Em to ee s => B. Total New Employee(s) (in Waiting Period) _> I C. Total Em to eels Other => 4 4. TOTAL ELIGIBLE EMPLOYEES (DETERMINES GROUP SIZE & PRODUCT) 1+2 Minus 3 => D. Total Em to ees with Other Covera e => 5. TOTAL ELIGIBLE FOR PARTICIPATION 4 Minus D => E. Total Refusals => 6. TOTAL ENROLLED 5 Minus E _> 143 7. EMPLOYEE PARTICIPATION (75% IS REQUIRED) 6 Divided b 5 => 97 Employers must have an application completed for all employees, even those who are not taking the health coverage, and submit those applications to Blue Cross and Blue Shield of Florida, Inc. and/or Health Options, Inc. It is recommended that the employer also retain a copy of all applications. I certify that the above information is cotTect to the best of my knowledge. I understand that this information will be used to determine my company's compliance with Blue Cross and Blue Shield of Florida, Inc. and/or Health Options, Inc. eligibility and Underwriting Guidelines. as we]] as the applicability of State and Federal laws relating to my company and plan. Blue Cross and Blue Shield of Florida, Inc. and/or Health Options, Inc. reserves the right to request a UCT-6 or other documentation as evidence of business activity at any time and from time to time in order to validate my compliance with eligibility and Underwriting Guidelines, as well as validate the applicability of State and Federal laws. Any pe on w owingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any fal~,, inc lete, or misleading information is guilty of a felony of the third degree. Group Officer's Signature City Manager Title 8/14/08 Date ~'` Blue Cross and Blue Shield of Florida, tnc. and Health Options, Inc. are Independent Licensees of the Blue Cross and Btue Shield Association, 7823 SR (Rev 1003) )®or~hield ,, ~, ~,~ ENROLLMENT SUMMARY COBRA COMP AN .F. ! .CK APPROPRIATE. R(1X1 ^ Ow company employed 20 or more full and/or part-time employees* dwing the previous calendaz year and is subject to federal COBRA. All full and part-time common taw employees of an employer are considered in determining COBRA compliance. All full time employees are counted as one employee and each part-time employee is counted as a fraction of an employee. ^ Our company employed fewer than 20 full and/or part-time employees* during the previous calendar year and is subject to the Florida Health Inswance Coverage Continuation Act ("FHICCA"). All full and part-time common law employees of an employer are considered in determining COBRA compliance. All full time employees are counted as one employee and each part-time employee is counted as a fraction of an employee. * For COBRA and FHICCA purposes, self-employed individuals, independent contractors and non-employee directors are not counted. MEDICARE SECONDARY PAYER OMP AN(`F !('HFl'K APPROPRIAT BOXI Mula'ple employer plan: a plan sponsored by more than one employer. Mu/tl-employer plan: a plan jointly sponsored by employers and unions. If you are a single employer plan: ^ Yes ^ No Ow company employed 20 or more employees** each working day in 20 or more calendar weeks (does not have to be consecutive weeks) dwing the current or preceding calendar year. If you are a single employer, multiple employer or a mu11i-employer plan: ^ Yes ^ No Ow company employed 100 or more employees* * on 50 percent or more of the business days dwing the preceding calendar year. If you are a multiple employer or amulti-employer pGrn: ^ Yes ^ No All employers in ow Group Health Plan (GHP) employed 20 or more employees* * for 20 or more consecutive weeks in either the current or preceding calendar year. ^ Yes ^ No At least one of the employers in our GHP employed 20 or more employees* * for 20 or more consecutive weeks in either the current or preceding calendaz year. ^ Yes ^ No All employers in ow GHP employed fewer than 20 employees** for 20 or more consecutive weeks in either the current or preceding calendar yeaz. ** "Employees" includes all full and/or part time emolovee ,::. ~t~enerall fortitalton ~ l~~"-'z ~~ ;,<~ ,~ .~~ ~ ', ti~ 1. Group Name CITY OF SEBASTIAN 2. Group Number Y4085 3. Group Sales Rep/Agent S dne Hod a 4. Effective Date 10/1/2007 5. Employer Contribution Toward Employees Premium (must be at least 50% for 1-50, 75% for 51+) 100% f7~. ecap~ut 1,ri p 4~ee T'i~i ttpa'tii ~'~ ~"~'-~ ' ~ i . S,.Y~. t . 1. TOTAL EMPLOYEES ON PAYROLL => 2. TOTAL COBRA CONTINiJANTS => 3. TOTAL INELIGIBLE EMPLOYEES Total of A+B+C => A. Total Part Time Em to ee s => B. Total New Employee(s) (in Waiting Period) _> C. Total Em to ee s Other => 4. TOTAL ELIGIBLE EMPLOYEES ETERMINES GROUP SIZE & PRODUCT) 1+2 Minus 3 => D. Total Em to ees with Other Covera a => 5. TOTAL ELIGIBLE FOR PARTICIPATION 4 Minus D => E. Total Refusals => 6. TOTAL ENROLLED 5 Minus E _> 7. EMPLOYEE PARTICIPATION (75% IS REQUIRED) 6 Divided 6 5 => Employers must have an application completed for all employees, even those who are not taking the health coverage, and submit those applications to Blue Cross and Blue Shield of Florida, Inc. and/or Health Options, Inc. It is recommended that the employer also retain a copy of all applications. I certify that the above information is wrrect to the best of my knowledge. I understand that this information will be used to determine my company's compliance with Blue Cross and Blue Shield of Florida, Inc. and/or Health Options, Inc. eligibility and Underwriting Guidelines, as well as the applicability of State and Federal laws relating to my company and plan. Blue Cross and Blue Shield of Florida, Inc. and/or Health Options, Inc. reserves the right to request a UCT-6 or other documentation as evidence of business activity at any time and from time to time in order to validate my compliance with eligibility and Underwriting Guidelines, as well as validate the applicability of State and Federal laws. / Any rson w owingly and with intent to injure, defraud, or deceive any inswer files a statement of claim or an application containing any e, in p~te, or misleading information is guilty of a felony of the third degree. Group Officer's Signatwe ~tr~~ ~~N~~~~ ~~-2~-a`7 Title Date 7823 SR (Rev 1003) Blue Cross and Blue Shield of Florida, Inc. and Health Options, Inc. are Independent Licensees of the Blue Cross and Blue Shield Association. B1ueG4~oae 131ueShleld '•' ~ °f ~'°~ ENROLLMENT SUMMARY • I~alth Oplt[ons, "~'naaR~w'~ eir.'~~ui~rrr~os~ .y su.en~u~r+.. COBRA COMPLIANCE (CHECK APPROPRIATE BOXI Our company employed 20 or more full and/or part-time employees* during the previous calendar year and is subject to federal COBRA. All full and part-time common law employees of an employer are considered in determining COBRA compliance. All full time employees are counted as one employee and each part-time employee is counted as a fraction of an employee. ^ Our company employed fewer than 20 full and/or part-time employees* during the previous calendar year and is subject to the Florida Health Insurance Coverage Continuation Act ("FHICCA"). All full and part-time common law employees of an employer are considered in determining COBRA compliance. All full time employees are counted as one employee and each part-time employee is counted as a fraction of an employee. * For COBRA and FHICCA purposes, self-employed individuals, independent contractors and non-employee directors are not counted. M EDICARE SECONDARY PAYER COMPLIANCE (CHECK APPROPRIATE BOXI Multiple employer plan: a pfan sponsored Fiy more than one employer-. Multi-employer plan: a plan join[ly sponsored by employers and unions. /f you are a single employer plan: ^ Yes ^ No Our company employed 20 or more employees** each working day in 20 or more calendar weeks (does not have to be consecutive weeks) during the current or preceding calendar year. If you are a single employer, multiple employer or amulti-employer plan: ^ Yes ^ No Our company employed 100 or more employees** on 50 percent or more of the business days during the preceding calendar year. If you are a multiple employer or amulti-employer plan: ^ Yes ^ No All employers in our Group Health Plan (GHP) employed 20 or more employees** for 20 or more consecutive weeks in either the curcent or preceding calendar year. ^ Yes ^ No At least one of the employers in our GHP employed 20 or more employees** for 20 or more consecutive weeks in either the current or preceding calendar year. ^ Yes ^ No All employers in our GHP employed fewer than 20 employees** for 20 or more consecutive weeks in either the current or preceding calendar year. also retain a copy of ail applications. I certify that the above information is correct to the best of my knowledge. I understand that this information will be used to determine my company's compliance with Blue Cross and Blue Shield of Florida, Inc. and/or Health Options, Inc. eligibility and Underwriting Guidelines, as well as the applicability of State and Federal laws relating to my company and plan_ Blue Cross and Blue Shield of Florida, Inc. and/or Health Options, Inc. reserves the right to request a UCT-6 or other documentation as evidence of business activity at any tame and from time to time in order to validate my compliance with eligibility and Underwriting Guidelines, as well as validate the applicability of State and Federal laws. Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree. Date Group Otlicer's Signature Title 7x2? SR (Rev Ill()?) Blue Cross and Blue Shield of Florida, Inc. and Health Options, Inc. are Independent Licensees of the Blue Cross and Blue Shield Association. Employers must have an application completed for all employees, even those who are not taking the health coverage, and submit those applications to Blue Cross and Blue Shield of Florida, Inc. and/or Health Options, Inc. It is recommended that the employer