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HomeMy WebLinkAboutHDHP Jan 1, 2013 benefits and coverage I= I.DIIP - SUiMMARY OF BENEFITS AND COVERAGE DOCUMENT AUTHORIZATION This authorization and agreement is made and entered into by City of Jeffersonville (the "Client ") and Humana insurance Company ("Humana"), effective January 1, 2013. This authorization and agreement concerns the establishment and development of a contractual relationship between Humana and the Client for providing the Summary of Benefits and Coverage ("SBC ") document with respect to the City of Jeffersonville Employee Health Plan (the "Plan "). The Client and Humana agree as follows: (a) Humana has created, on behalf of the Client, the SBC document based on benefits and provisions described in the New Case Document. (b) By signing this authorization, the Client agrees that the benefits and provisions outlined in this SBC document, draft numbered 1 are accurate and approved by the Client. (c) I will create a final SBC for the Client. The Client is responsible for the distribution of the SBC document to its plan participants. At the request of the Client, if the final Summary Plan Description (SPD) has been approved, Humana will attach the approved SBC within the approved SPI_) and the combined document will be available to plan participants on Humana's website. The Client and Huri n i have caused this agreement to be executed by their respective officers or representatives as duly authorized. 'I`IIE CI..,IF'N' B v: Date:, ? 3 v Accepted: HUMANA INSURANCE COMPANY Khalid ti izir Vice President el Q_ 4,3 it �I " • O = v v 0 � 7' ad • A v r CU 4-, v ct A, _ - O O v v v v O A" ti bA p N �+ U ,4 it U O , O v ' O O = o cr 71 i (-A ' at u a) 0 4 7-1 : . ,, _ : 0 . -0 ca .� v �„ 4, � , o 1 X p N v 4 ; a� q 5 o L v O O v s-+ w O °� v A v) : 3..� U O v A ' ; O O m t Q. C1 v - d . � O 0 N -0 0 O ° ccr b a s • ' a O ,t, v , U : v O v : A., ` a.) a 0 , A., . � . ' ! O CI O v A p. v O • O b A 4 ✓ v V) • u b w + O f O v ci ? 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