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Contract to Purchase Logo Design and Rights - Excel

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					                Request for Proposal (RFP) for Lake County Board of County Commissioners
               Long-Term Disability and Short-Term Disability

               To Vendor: Use Column G to provide a brief explanation. However if the
               length of the explanation is greater than 400 characters, you must use the
               "Explanation" worksheet to provide your detail explanation.


               STD/LTD RFP FOR 2008                                                         Answer Format        Response   Explanation

  I.           PLAN IDENTIFICATION/CONTACTS                                                 Answer Format        Response   Explanation
        1.     Disability Carrier Legal Name                                                    text
        2.     Disability Carrier Marketing Name                                                text
        3.     Street Address                                                                   text
        4.     City                                                                             text
        5.     State                                                                            text
        6.     Zip                                                                              text
        7.     Telephone #                                                                      text
        8.     Fax Phone #                                                                      text
        9.     Web Address                                                                      text
       10.     Taxpayer ID #                                                                    text


II.            GENERAL PLAN INFORMATION                                                     Answer Format        Response   Explanation
        1.     Disability Carrier Operational Date                                          mm/dd/yyyy
                                                                                             For-Profit
        2.     Corporate Tax Status
                                                                                            Not-for-Profit
        3.     Disability Carrier Ownership/Controlling Interest                                 text
        4.     STD covered lives (all funding types)                                        covered lives
        5.     LTD covered lives (all funding types)                                        covered lives

               Use the "Explanation" column and/or worksheet to discuss
               any recent or planned merger, acquisition or divestiture
        6.     activities that may impact the administration of this program. For               text
               each activity, indicate the timing, expected/potential impact and
               plans to mitigate any adverse effects.


               Financial Ratings                                                            Answer Format        Response   Explanation
               Disability Carrier's most recent rating or filing (identify
        7.
               date) from each of the following agencies:
             a. A.M. Best: Rating Status
                  Financial Rating (if rated)                                                   text
                  Date (if rated; if not rated, leave response cell blank)                   mm/dd/yyyy
             b. Standard & Poor's: Rating Status
                  Financial Rating (if rated)                                                   text
                  Date (if rated; if not rated, leave response cell blank)                   mm/dd/yyyy
             c. Fitch: Rating Status
                  Financial Rating (if rated)                                                   text
                  Date (if rated; if not rated, leave response cell blank)                   mm/dd/yyyy
             d. Moody's: Rating Status
                  Financial Rating (if rated)                                                   text
                  Date (if rated; if not rated, leave response cell blank)                   mm/dd/yyyy
                Disability Carrier's rating change within the past 12
        8.
                months:
             a. A.M. Best                                                                       text
             b. Standard & Poor's                                                               text
             c. Fitch                                                                           text
             d. Moody's                                                                         text


III.           PLAN DESIGN/FINANCIAL INFORMATION                                            Answer Format        Response   Explanation
               The quotation is to be based on the census, plan design,
               historical premiums (if applicable), and experience/claims
               data (if provided). Adhere to the proposed plan design
               shown in the worksheets, "Plan Design..." in preparing the
               quote.
               The proposal is issued in accordance with the specifications,
               assumptions and information included in this Request for
        1.                                                                                     Yes/No
               Proposal, and the accompanying worksheets. If "No", indicate
               deviations in "Explanation" column and/or worksheet.

               Proposal contains the form (included in the worksheet,
        2.     "Officer"), signed by a company officer, attesting to compliance                Yes/No
               with RFP specifications and the accuracy of all responses.



        28641ffd-1c95-48b5-95aa-6dec1ee671b7.xlsQuestionnaire8/16/2011                                 1 of 17
           Plan Design                                                          Answer Format       Response   Explanation
           Review and detail deviations from the proposed plan design
 3.                                                                                 Yes/No
           shown in the worksheet, "Plan Design."


           Financial - Program Fees                                             Answer Format       Response   Explanation
           Did you provide your financial quotation in the worksheet(s)
 4.                                                                                 Yes/No
           "RateQuote."
 5.        Are you agreeable to offering a 3-year rate guarantee?                   Yes/No
           If you are providing rate guarantees or rate caps beyond the first
 6.        contract period, have you included the rates or caps in the              Yes/No
           financial quotation?
 7.        The quoted STD rates are net of commissions.                             Yes/No
 8.        The quoted LTD rates are net of commissions.                             Yes/No


           Other Financial                                                      Answer Format       Response   Explanation
 9.        Will you:

      a. Pay FICA during the first 6 months of a claimant's disability?             Yes/No

      b. Provide FICA reports at least monthly?                                     Yes/No
       Prepare supplemental W-2s at the close of each calendar year,
      c.                                                                            Yes/No
       as requested?
       Deduct the employee portion of health care costs from disability
    d.                                                                              Yes/No
       payments?
       Deduct all appropriate taxes (federal and state) from disability
    e.                                                                              Yes/No
       payments?
       Provide a magnetic tape containing supplemental W-2
    f.                                                                              Yes/No
       information.
       If there are additional costs for any of the above, make sure
10.                                                                                 Yes/No
       these costs are included in your quotation.
11.    Does your LTD quote include the Employer's FICA match?                       Yes/No
           Does your LTD proposal include Social Security appeals
12.                                                                                 Yes/No
           support?
13.        Do you provide for an integrated STD/LTD plan?                           Yes/No
           Are your STD and LTD Rehabiitation benefits voluntary or                Voluntary/
14.
           mandatory?                                                             Mandatory
           Do you offer telephonic and/or online (electronic) STD claims          Telephonic/
15.
           intake?                                                                Online/Both
16.        Are STD benefits paid on a 5-day or 7-day per week formula?            5-day/7-day
                                                                                   30 days
           What is the length of the grace period you will permit for late         60 days
17.
           payment of premiums.                                                    90 days
                                                                                Other - see Expl
           Will you extend your grace period by 30 days in the event of a
18.                                                                                 Yes/No
           declared emergency?
19.        Indicate the interest charge used for late payments.                   Percentage


           Financial - Renewal Services                                         Answer Format       Response   Explanation
           Renewal rates (to be accompanied with an experience summary
20.        report) are to be provided at least 180 days in advance of the           Yes/No
           contract anniversary date. Can you meet this requirement?

           Subsequent renewals shall be guaranteed for a minimum of 12
           months from the contract anniversary date, unless an alternate
21.                                                                                 Yes/No
           date is mutually agreed to in advance by The County. Can you
           meet this requirement?
           For the funding arrangement requested in this RFP, please
22.        indicate your willingness to comply with the following
           renewal requirements and services:
      a. Full description of the methodology used to calculate renewals.            Yes/No

      b. Full description of the methodology used to calculate reserves.            Yes/No

           A definition of all terms and an itemization of all assumptions
      c.                                                                            Yes/No
           used including projected claims and the formula involved.

           Estimated or actual identification of expenses, including IBNR,
      d.                                                                            Yes/No
           claim administration expense and other expenses.
      e. Allocation of your administrative cost projections.                        Yes/No
      f. Premium rate justification.                                                Yes/No
      g. Comparison of old and new rates and factors.                               Yes/No




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               Describe in detail your credibility formula and the impact of the
               formula on The County. What factors would improve credibility
               (e.g. reduced maximum benefit)? What impact would these
      23.                                                                               text
               factors have? If you need more space, please use the
               "Explanation" column. If you need more space, please use the
               "Explanation" worksheet. Indicate the question answered.


IV.            REPORTING (Management Reports)                                      Answer Format         Response   Explanation
               Attach sample management report(s) that would be prepared for
                                                                                    Attached/Not
       1.      The Client. Name the file: [Your Organization's
                                                                                      Attached
               Name]_Management Reporting Package.


               Monthly and Quarterly                                               Answer Format         Response   Explanation
               During the vendor selection process, Lake County will negotiate
       2.                                                                          Agree/Disagree
               the content of monthly and quarterly standard reports.

       3.      Reports will reflect experience by:
            a. Employees lives exposed by month                                       Yes/No
            b. Disabled employees                                                     Yes/No
            c. Social Security status                                                 Yes/No
            d. Reserves by claimant                                                   Yes/No
            e. Nature of disability (number and value of claims)                      Yes/No
            f. Primary diagnosis by ICD-9 (CM)                                        Yes/No
            g. Diagnosis by DSM-IV                                                    Yes/No
            h. Demographics of claimants                                              Yes/No
            i. Duration of disability compared to norms                               Yes/No
       4.      Reports will include the following claimant data:
            a. Date of birth                                                          Yes/No
            b. Date of disability                                                     Yes/No
            c. Gender                                                                 Yes/No
            d. Gross benefit                                                          Yes/No
            e. Social Security offset                                                 Yes/No
            f. Other offsets                                                          Yes/No
            g. Net benefit                                                            Yes/No
            h. Cause of disability                                                    Yes/No
            i. Estimated return to work date                                          Yes/No

               Monthly and quarterly reports will be available no later than the
       5.                                                                             Yes/No
               end of the month following the close of the period in question.


               Annual Reports                                                      Answer Format         Response   Explanation
               A year-end financial accounting for the program within 60 days
       6.                                                                             Yes/No
               of the contract anniversary date.
               Annual generation of eligibility listing in hard copy or ASCII
       7.                                                                             Yes/No
               format diskette.
               Information required for compliance with the filing of IRS Form
       8.      5500. (The County requests this information even though it             Yes/No
               is not required.)


V.             ADMINISTRATIVE AND OPERATIONAL ISSUES                               Answer Format         Response   Explanation
               Implementation and Ongoing Services
               Indicate your willingness to comply with the following
               services/statements.
               STD Claims will be transitioned on an incurred basis starting
               with claims incurred on or after 10/1/2008. Claims incurred on
       1.      or after this date will be the responsibility of the new carrier.   Agree/Disagree
               Claims incurred prior to 10/1/2008 will continue to be the
               responsibility of the incumbent carrier.
               LTD Claims will be transitioned on an incurred basis starting
               with claims incurred on or after 10/1/2008. Claims incurred on
       2.      or after this date will be the responsibility of the new carrier.   Agree/Disagree
               Claims incurred prior to 10/1/2008 will continue to be the
               responsibility of the incumbent carrier.
               Process benefit payments to STD beneficiaries on a weekly
       3.                                                                          Agree/Disagree
               basis.
               Process benefit payments to LTD beneficiaries on a monthly
       4.                                                                          Agree/Disagree
               basis.
               Review all plans, draft plan abstracts, and confirm plan
       5.                                                                          Agree/Disagree
               provisions with The County.
               Draft, revise, and finalize the policy and benefit summaries
       6.      (booklets) for review by The County at least 30 days prior to the   Agree/Disagree
               effective date.




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         Provide all reasonable assistance as may be requested during
 7.      the transition period, including participation at employee           Agree/Disagree
         meetings.
         Deliver an Administration Manual containing all usual guidelines
 8.      on such matters as eligibility, reports, plan summaries and          Agree/Disagree
         procedures.
         Prepare a detailed schedule and time frames to implement this
         program by the effective date, including vendor responsibilities
 9.                                                                           Agree/Disagree
         and those of The County. Name the file: [Your Organization's
         Name]_Implementation Schedule.
         Attach a description of premium or administrative fee billing
         procedures. Include information on the timing of billing, billing-
10.      payment reconciliations, and ability to provide self-billing. Name   Agree/Disagree
         the file: [Your Organization's Name]_Premium Billing
         Process Description.
         When customized printing is requested by The County, present
         a complete draft and subsequent proof to The County for sign-
11.                                                                           Agree/Disagree
         off. The vendor must ensure that logo placement and color
         requirements are met.
         Be responsible for costs of printing booklets, certificates, or
12.                                                                           Agree/Disagree
         SPDs as required.
         Provide SPDs in an electronic format for access via internet or
13.                                                                           Agree/Disagree
         intranet.
         Refrain from issuing any external communications material that
         mentions The County's benefit plans without written approval
14.                                                                           Agree/Disagree
         from The County. This includes newsletters and publications to
         agents, brokers and consultants.
         Permit The County to decline the Account Manager designated
15.                                                                           Agree/Disagree
         for its programs both initially and in future years.
         Upon request, supply brief biographies of all key individuals that
16.                                                                           Agree/Disagree
         will be responsible for this account.
17.      Sign contract within 90 days of effective date.                      Agree/Disagree
18.      Provide routine underwriting and actuarial services.                 Agree/Disagree
       Indicate your willingness to offer the following web-based
19.
       services:
20. a. Enrollment and termination                                             Agree/Disagree
      b. Claim filing                                                         Agree/Disagree
      c. Claim tracking                                                       Agree/Disagree


         Service Centers                                                      Answer Format      Response   Explanation
         List the location of your service center(s) that would be
         servicing The County's employees and the corresponding
         geographic areas/regions covered by the respective
21.
         location. If more than one service center will be assigned
         to service The County, provide additional information in the
         "Explanation" column and/or worksheet.
                                                                               service center
      a. Name of service center
                                                                                  location
    b. Geographic Region Covered                                              region covered
       Indicate specific times member service representatives are
       available to answer member questions. Use Eastern
22.    Standard Time (EST) for reporting all times below. Do not
       include hours for answering services, recordings or
       nurse/health information lines:
    a. Hours of operation weekdays - Opens                                         Time
      b. Hours of operation weekdays - Closes                                      Time
      c. Hours of operation on Saturday - Opens                                    Time
      d. Hours of operation on Saturday - Closes                                   Time
      e. Hours of operation on Sunday - Opens                                      Time
      f. Hours of operation on Sunday - Closes                                     Time
       What percentage of all member services inquiries during
23.                                                                             Percentage          .
       2007were closed (issue resolved) on first contact?
       The member services phone system has voice messaging
24.                                                                               Yes/No
       capabilities.
       List below all services that you would subcontract under
25.
       this program with The County.
    a. STD
            Service #1                                                        name of service
            Service #2                                                        name of service
            Service #3                                                        name of service
            Service #4                                                        name of service
      a. LTD
            Service #1                                                        name of service
            Service #2                                                        name of service
            Service #3                                                        name of service
            Service #4                                                        name of service



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             Vendor agrees to be held liable for the performance of any
      26.                                                                            Agree/Disagree
             subcontracted services.


VI.          LEGAL/CONTRACTUAL CONSIDERATIONS                                        Answer Format         Response   Explanation
             Please confirm that your organization has complied with all state
             insurance department filing requirements for all plans/products
       1.                                                                               Yes/No
             being offered in this quote in each state in which The County
             has employees.
             Comment : Be sure to review the census file submitted with this RFP.
             If the answer to the preceding question is "no", for all
             plans/products quoted in this RFP for which the required state
          a. insurance department filing requirements have not been met,                  text
             please specify the applicable plan/product and corresponding
             state.
             We understand that terminology and contract provisions
             may vary from vendor to vendor. We will permit such
             alternative language, provided they are reviewed and
             approved by The County.
       2.    Contract will be issued in Florida.                                        Yes/No
       3.    October 1, 2008 will be the contract effective date.                       Yes/No
       4.    October 1, 2011 will be the first contract anniversary date.               Yes/No
             The County reserves the right to terminate its contract at any
       5.    time, provided such notification is given at least 30 days in              Yes/No
             advance.
             In the event of policy termination, either on or off policy
       6.    anniversary date, you will fully account for all reserves and              Yes/No
             return to The County any unused portion.
             There will be no restrictions or benefit limitations for pre-existing
       7.                                                                               Yes/No
             conditions applied to any employee under the plan.
             Vendor unconditionally agrees to provide coverage to all
             present participants enrolled on the program effective date. No
       8.                                                                               Yes/No
             active employees or disabled employees shall lose coverage as
             a result of a change in vendor.
             Vendor agrees to a "no loss, no gain" provision and to
       9.    unconditionally provide continuous coverage to all current                 Yes/No
             participants.
             No statement of health or medical evidence will be imposed
      10.                                                                               Yes/No
             upon the initial group of covered employees.
             Any "actively at work" requirements will be waived for current
      11.                                                                               Yes/No
             covered employees.
             Any disabled employees or other leave-of-absence employees
             who are not disclosed in these specifications or who later are
      12.    identified as eligible for benefits under the prior vendor will            Yes/No
             become the liability of the new vendor following termination of
             the prior contract.
             The County reserves the right to audit the program at least once
      13.                                                                               Yes/No
             annually.
             Vendor will provide on-site access to any and all claims
             information for audit; will permit access to such information by
      14.    claims and disability management personnel necessary to                    Yes/No
             complete the audit; and agrees to do so at no cost to The
             County.
             In the event of policy termination, the selected vendor will be
      15.    responsible for incurred claims up to the termination date for             Yes/No
             fully-insured coverages.
             The vendor must agree to transfer to The County, within 30 days
             of notice of termination, all required data and records necessary
             to administer the plans subject to state and federal
      16.    confidentiality considerations. The transfer may be made                   Yes/No
             electronically, in a file format to be determined based on the
             mutual agreement between The County and the provider of
             services.
             Please note that The County will neither recognize the
             appointment of any agent, general agent, or broker by a
      17.    respondent to these bid specifications, nor authorize any                  Yes/No
             payment or remuneration of any kind by a vendor to a party not
             approved in writing by The County.
             All financial and claimant information will be kept confidential
      18.    and will not be disclosed to any other party without The County's          Yes/No
             express approval.
             Effective for claims filed on or after January 1, 2005, Vendor
             certifies that it will comply with the Department of Labor's final
      19.    claims procedure regulations, including the appropriate                    Yes/No
             timeframes for (a) adjudicating claims, and (b) notice of appeal
             decisions.
             If asked by The County, vendor agrees to assume claim
             fiduciary responsibilities, including appeals, for claim
      20.                                                                               Yes/No
             adjudication and defense of claim decisions. The County
             understands this may involve additional cost.
             Vendor agrees to provide necessary legal defense in the event
      21.                                                                               Yes/No
             of litigation, including all costs.




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                Vendor agrees to prepare and file all legal documents
                necessary to implement and maintain the plan, including
       22.                                                                               Yes/No
                policies, amendments, contracts, required state filings, and
                development of booklet/certificate formats.
                Vendor agrees to monitor federal and state legislation affecting
                the delivery of disability benefits under the plan and to report to
       23.                                                                               Yes/No
                The County on those issues in a timely fashion prior to the
                effective date of any mandated plan changes.
                Vendor agrees to the Hold Harmless language set forth in the
       24.                                                                               Yes/No
                worksheet, "Hold Harmless."
                You agree to incorporate the following wording in the purchasing
                code into the agreement with the County.

                "After notification of award, the successful Proposer shall
       25.      Indemnify and Save Harmless the County as specified in Florida           Yes/No
                Statutes Section 725.06. Nothing in the award, resulting
                agreement, contract or purchase order shall be deemed to affect
                the rights, privileges and immunities of the County as set forth in
                Florida Statutes."
       26.      Briefly describe your termination clause.                                 text


VII.            OTHER INFORMATION                                                     Answer Format        Response   Explanation
                Provide the following additional information.

                A copy of a suggested Employer Contract with a statement that
                the sample includes all exclusions and limitations that will apply    Attached/Not
        1.
                to a policy issued to The County. Name the file: [Your                  Attached
                Organization's Name]_Sample Employer Contract.

                A copy of the carrier's appeal and grievance policies, if not
                                                                                      Attached/Not
        2.      specified in the Sample Employer Contract. Name the file:
                                                                                        Attached
                [Your Organization's Name]_Appeal and Grievance Policies.


                Customer Service                                                      Answer Format        Response   Explanation
                Please fill in the names and titles of the persons who will be
                assigned to the following customer service tasks.

        3.      Sales Representative
             a. Name                                                                      text
             b. Title                                                                     text
             c. Phone #                                                                   text
             d. Fax Phone #                                                               text
             e. E-mail Address                                                            text
        4.      Account Executive
             a. Name                                                                      text
             b. Title                                                                     text
             c. Phone #                                                                   text
             d. Fax Phone #                                                               text
             e. E-mail Address                                                            text
        5.      Service Representative
             a. Name                                                                      text
             b. Title                                                                     text
             c. Phone #                                                                   text
             d. Fax Phone #                                                               text
             e. E-mail Address                                                            text
        6.      Claims Contact
             a. Name                                                                      text
             b. Title                                                                     text
             c. Phone #                                                                   text
             d. Fax Phone #                                                               text
             e. E-mail Address                                                            text
        7.      Billing Contact
             a. Name                                                                      text
             b. Title                                                                     text
             c. Phone #                                                                   text
             d. Fax Phone #                                                               text
             e. E-mail Address                                                            text


                References                                                            Answer Format        Response   Explanation
                Please provide three references of Clients similar in employee
        5.      size and industry to The County currently using services
                requested in this RFP.
             a. Reference #1



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         Company Name                                             text
         Contact Person                                           text
         Title                                                    text
         Phone #                                                  text
         Fax Phone #                                              text
         E-mail Address                                           text
         Number of covered employees by coverage type            Number
         List coverages in place similar those this RFP.          text
   b. Reference #2
         Company Name                                             text
         Contact Person                                           text
         Title                                                    text
         Phone #                                                  text
         Fax Phone #                                              text
         E-mail Address                                           text
         Number of covered employees by coverage type            Number
         List coverages in place similar those this RFP.          text
   c. Reference #3
         Company Name                                             text
         Contact Person                                           text
         Title                                                    text
         Phone #                                                  text
         Fax Phone #                                              text
         E-mail Address                                           text
         Number of covered employees by coverage type            Number
         List coverages in place similar those this RFP.          text
      Please provide at least three references of companies of
6.    similar size to The County who have terminated your
      services.
   a. Reference #1
         Company Name                                             text
         Contact Person                                           text
         Title                                                    text
         Phone #                                                  text
         # Employees covered under your contract                 Number
         Nature of Business                                       text
   b. Reference #2
         Company Name                                             text
         Contact Person                                           text
         Title                                                    text
         Phone #                                                  text
         # Employees covered under your contract                 Number
         Nature of Business                                       text
   c. Reference #3
         Company Name                                             text
         Contact Person                                           text
         Title                                                    text
         Phone #                                                  text
         # Employees covered under your contract                 Number
         Nature of Business                                       text




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Request for Proposal (RFP) for Lake County Board of County Commissioners
Explanation

Use this worksheet to provide additional explanation for any questions for which a "no" response was given.
Explanations must be numbered to correspond to the question to which they pertain and they must be brief.

State the number of questions you addressed with further explanation:

Section/                                                                Explanation
Question #




     28641ffd-1c95-48b5-95aa-6dec1ee671b7.xlsExplanation8/16/2011 8 of 17
28641ffd-1c95-48b5-95aa-6dec1ee671b7.xlsExplanation8/16/2011 9 of 17
Request for Proposal (RFP) for Lake County Board of County Commissioners
Plan Design - LTD

      You must Indicate any deviations from the Certificate of Coverage as well as this summary plan design.
                                                                          IN-FORCE PLAN DESIGN                  DEVIATIONS
            LTD BENEFIT PROVISIONS
Current Carrier                                                                     Unum
Effective Date of Plan                                                       October 1, 2001
                                                                       1st of month after 30 days;
Eligibility
                                                                         all full-time employees
Benefit Percentage                                                                   60%
                                                                           Greater of $100 or
Minimum Monthly Benefit
                                                                     10% of gross disability payment
Maxium Monthly Benefit                                                              $5,000
Elimination Period
     Basic - Employer-paid                                                      180 days
     Buy-up - Employee paid                                                     90 days
Contributions
     Basic                                                                 100% Employer-paid
     Buy-up                                                            Difference paid by Employee
Maximum Benefit Duration                                        To age 65 (see below reduction schedule)
Social Security Integration                                                       Family
                                                             Worker's Compensation, other group insurance
                                                              plans, any governmental retirement systems,
Benefit Offsets                                                   retirement amounts with the sponsor,
                                                             retirement/disability amounts under the United
                                                                States Social Security Act, The Jones Act
Mental & Nervous/Substance Abuse Limit                                          24 months
Neuromusculoskeletal/Soft Tissue Limit                                              N/A
Subjective Illness Limit                                                            N/A
Self-reported Symptoms Limit                                                    24 months
Survivor Benefit                                                           3 months (lump sum)
Own Occupation Period
     All Safety Employees                                                       12 months
     All Other Employees                                                        24 months
Any Occupation Period
     All Safety Employees                                                      To age 65
     All Other Employees                                                       To age 65
Zero Day Residual                                                                  N/A
Partial Disability Provision                                                    Included
                                                                Additional 10% of gross disability payment
Rehabilitation Benefit
                                                                    to maximum of $1,000 per month
COLA Benefits                                                                     None
Pre-existing Condition                                                             3/12
Premium Waiver                                                                     Yes
Conversion                                                                          No
                   DEFINITIONS
Own Occupation                                              Unable to perform material and substantial duties
                                                                       of your regular occupation
Any Occupation                                               Unable to perform the material and substantial
                                                            duties of any job which you are reasonably fitted
                                                                  by education, training or experience
Benefit Reduction Schedule
     Age at Disability                                                    Benefit Duration
        < 60                                                           To age 65; min. 5 years
        60                                                                    60 months
        61                                                                    48 months
        62                                                                    42 months
        63                                                                    36 months
        64                                                                    30 months
        65                                                                    24 months
        66                                                                    21 months
        67                                                                    18 months
        68                                                                    15 months
        69 +                                                                  12 months
Pre-ex Prudent Person                                      Symptoms for which an ordinarily prudent person
                                                           would have consulted a health care provider

Self Reported                                              Manifestations of a condition which you tell your
                                                           physician, that are not verifiable using tests,
                                                           procedures or clinical examinations standardly
                                                           accepted in the practice of medicine


         28641ffd-1c95-48b5-95aa-6dec1ee671b7.xlsPlanDesignLTD8/16/2011             10 of 17
Request for Proposal (RFP) for Lake County Board of County Commissioners
Plan Design - STD

                                                     This is a newly proposed plan option.
                                                           PROPOSED PLAN DESIGN                  DEVIATIONS
        STD BENEFIT PROVISIONS
Weekly Benefit (% of weekly earnings)                                    60%
Minimum Weekly Benefit                                                   $25
Maximum Weekly Benefit                                                 $1,000
Waiting Period                                                         1 week
Elimination Period-Injury                                              1st Day
Elimination Period -Sickness                                           8th Day
Benefit Duration (Weeks)                                                  12
             POLICY FEATURES
Actively at Work                                                         Yes
Pre-existing Condition                                                  None
                                                     Worker's Compensation, other group
                                                 insurance plans, any governmental retirement
                                                     systems, retirement amounts with the
Benefit Offsets
                                                  sponsor, retirement/disability amounts under
                                                   the United States Social Security Act, The
                                                                      Jones Act
Definition of Earnings                                             W-2 earnings
Definition of Disabiity                                          Own occupation
Evidence of Insurability                                    Required for late entrants
Eligibility Waiting Period                                 1st of month after 30 days;
                                                             all full-time employees
Contributions
   Option 1                                                 Voluntary - Employer-paid
   Option 2                                                 Voluntary - Employee-paid




      28641ffd-1c95-48b5-95aa-6dec1ee671b7.xlsPlanDesignSTD8/16/2011    11 of 17
Request for Proposal (RFP) for Lake County Board of County Commissioners
Census

A file is included with the RFP documents (filename: LTD-STD RFP Census.xls). Two worksheets are included:
1) New Hires          2) Census

  Column                                      Data Elements
     A       Employee ID
     B       Agency (BCC, Water Authority, Property Appraiser)
     C       Status
     D       Gender
     E       Date of Birth
     F       Date of Hire
     G       Zip Code
     H       Annual Salary
     I       Description
     J       Covered Payroll
     K       Weekly Payroll @ 60%




     28641ffd-1c95-48b5-95aa-6dec1ee671b7.xlsCensus8/16/2011   12 of 17
Request for Proposal (RFP) for Lake County Board of County Commissioners
Current Rates and Rate History

                    Rates Per $100                            10/1/05 - 9/30/08
LTD - Basic (180-day elimination period)                           $0.28
LTD - Buy-up (90-day elimination period)                           $0.51

                      Rate History
Current rates have been in effect since 10/1/05 and are currently guaranteed through 9/30/08.




     28641ffd-1c95-48b5-95aa-6dec1ee671b7.xlsRates8/16/2011    13 of 17
Request for Proposal (RFP) for Lake County Board of County Commissioners
Claims Experience
             Current       Current Status                                   Total Paid
   ID #                                                      Reason                      Gender   Date of Birth   Date of Disability
             Status             Date                                         to Date
  5218        Open          10/12/2007            Decision Pending               -         M        10/6/1947         4/15/2007
  5231        Open          10/08/2007            Payment in Process             -         F       12/26/1950         4/11/2007
  1326        Open          11/14/2006            Payment in Process         $16,214       F        2/11/1951         8/16/2006
  2491       Closed         06/08/2006            Death - Non-Compensable        -         F       10/17/1951          4/2/2006
  1113       Closed         03/16/2006            Death                        $800        M         7/3/1951         4/20/2005
  7765        Open          07/14/2005            Payment in Process         $29,112       F       10/20/1941         4/14/2005
  9448        Open          10/05/2005            Payment in Process          $4,344       M         6/3/1953          4/8/2005
  1786       Closed         09/05/2004            Death - Non-Compensable        -         M        5/29/1949          8/7/2004
  9388       Closed         05/28/2006            Death                       $9,857       M       12/13/1949         7/26/2003
  8263        Open          01/02/2004            Payment in Process         $32,272       M         2/4/1950          7/6/2003
  2125       Closed         06/16/2004            No Longer Disabled         $20,096       M        8/12/1951         6/18/2003
  4053       Closed         01/05/2007            Maximum Benefits            $5,840       M        8/17/1940          1/7/2003
  4439        Open          06/07/2002            Payment in Process         $54,103       F        5/29/1955          3/9/2002
   614       Closed         01/30/2004            No Longer Disabled          $4,508       F        3/25/1942          2/6/2002




    28641ffd-1c95-48b5-95aa-6dec1ee671b7.xlsExperience8/16/2011             14 of 17
Request for Proposal (RFP) for Lake County Board of County Commissioners
Rate Quote - LTD

RATE QUOTE                                           Inforce Plan Design - Basic   Inforce Plan Design - Buy-up
Covered Lives                                                     863                          863
Covered Payroll (Annual)                                      $37,213,645                  $15,138,573
Monthly Rate
Per (Monthly Covered Payroll)                                     $100                        $100
Monthly Premium                                                   $0.00                       $0.00
Annual Premium                                                    $0.00                       $0.00
FINANCIAL EXHIBIT EXPERIENCE-RATED CONTRACTS
Retention
 Taxes
 Commissions
 Risk Charges
 All Other Expenses
 Total Retention
UNDERWRITING ISSUES
Rate Guarantee Period
Census Change Tolerance %
Pooled or Dividend Participating
Experience Rated
Credibility in Year 2
Expected Loss Ratio
Minimum Employee Participation Required




                                                               15 of
     28641ffd-1c95-48b5-95aa-6dec1ee671b7.xlsRateQuoteLTD8/16/2011 17
Request for Proposal (RFP) for Lake County Board of County Commissioners
Rate Quote - Fully-Insured STD
              This is a not a current benefit. Covered lives are illustrated as all eligible employees.

                                                                Option 1:                     Option 2:
RATE QUOTE                                              Voluntary - Employer-Paid     Voluntary - Employee-Paid
Covered Lives                                                       863                           863
Volume of Weekly Benefit                                       $608,404.82                   $608,404.82
Monthly Rate
Per (Weekly Covered Payroll)                                       $10.00                        $10.00
Monthly Premium                                                     $0.00                         $0.00
Annual Premium                                                      $0.00                         $0.00
UNDERWRITING ISSUES
Rate guarantee period
Census change tolerance %
Pooled or Dividend Participating
Experience Rated
Credibility in year 2
Expected Loss Ratio
Minimum Employee Participation Required
Other Underwriting Requirements
ALTERNATE RATE QUOTE FOR VOLUNTARY (per $10 Benefit Volume):
                                                                        <20
                                                                       20-24
                                                                       25-29
                                                                       30-34
                                                                       35-39
                                                                       40-44
                                                                       45-49
                                                                       50-54
                                                                       55-59
                                                                       60-64
                                                                       65-69
                                                                        70+




                                                              16 of
    28641ffd-1c95-48b5-95aa-6dec1ee671b7.xlsRateQuoteSTD8/16/2011 17
Request for Proposal (RFP) for Lake County Board of County Commissioners
Officer Certification
Please have an Officer review and sign this worksheet to confirm the information is valid.
Please include the completed form with your proposal.

                                               OFFICER'S STATEMENT
Disability Carrier Legal Name
Disability Carrier Marketing Name
Street Address
City
State
Zip
Phone Number
Fax Number
Web Address
Name of Officer completing statement
Title of Officer completing statement
Phone Number of Officer completing statement
Email Address of Officer completing statement


I certify that our response to Lake County Board of County Commissioner's Long-Term Disability and Short-Term
Disability Request for Proposal is complete and accurate to the best of my knowledge and contains no material
omissions or misstatements. I acknowledge that Lake County Board of County Commissioners will rely upon the
information included in our response to make decisions concerning the disability benefits that are offered to their
employees.



Officer's Signature


Date Signed




                                     28641ffd-1c95-48b5-95aa-6dec1ee671b7.xlsOfficer8/16/2011                         17 of 17

				
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