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HomeMy WebLinkAboutJan 1, 2013 effective Humana PPO benefits/coverage PPO - SUMMARY OF BENEFITS AND COVERAGE DOCUMENT AUTHORIZATION This authorization and agreement is rnade and entered into by City of Jeffersonville (the "Client") and Humana insurance Company (Humana"). effective January 1, 201 3. This authorization and agreement concerns the establishment and development of a contractual relationship between Humana and the Client for providing the Suonmuzy of Benefits and Coverage ("SBC") document with respect to the City ofJeffersonville Einployee Health P!an (the 'P1an'). The Client and Huinaria agree as fb||mvs: (a) Humana has crne/ed, on behalf of the Client, the SBC document based on benefits and provisions described in the New Case Docunient. (b) By signing this authorization, the Client agrees that the benefits and provisions outlined in this SBC document, draft nwnbered l are accurate and approved by the Client. (c) Humana will create a final SBC for the Client. The Client is ncopnnoiblefbr/be dimdbutinuof/be SBC document to its plan participants. At the request of the Client, if the final Summary Plan Description ( has been upproved. Humana will attach the approved SBC within the approved SPD and the combined document will be available to plan participants on Humana's website. ' The Client and Humana have caused this agreement to be executed by their respective officers or representatives as duly authoriz THE By: 1 \-) ' ---' Date: Accepted: D0MANA INSURANCE COMPANY � ^ u _ *�_��=~�_~ ~ `w4~W�~�� xp Khalid \azir Vice President: o0 • U v - ; a c 0 v a U v a� v v O .. 3-I v CA • F- ft i CI j , M y O ct '+ O i • CNI a U d 0 b �, O a v -. 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