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Cigna Group Insurance Cigna Requirements Document Accidental Injury Critical Illness
Hospital Care
The purpose of this document is to define the requirements needed to ensure operational readiness and the issuance of accurate Policies and Certificates. This document is intended as a guide for the gathering of information required to implement all programs. Please note: Selections/choices outside of items previously agreed to during the pre-sale process may be subject to fees in addition to the original fees agreed upon, and may require an approval from underwriting in order to be implemented.
UNDERWRITING COMPANY Life Insurance Company of North America
Cigna Life Insurance Company of New York
Documents for Customer Signature
Document for Client Review
Appointment of Claim Fiduciary
Privacy Notice Disclosure of Producer Compensation Practices
EMPLOYER INFORMATION - SECTION 1 Complete for all coverages
EMPLOYER FULL LEGAL NAME - Please include exact abbreviations, punctuation and /or capitalization.
COMPANY TAX ID #
Aspect Software, Inc.
02-0364368
STREET ADDRESS
CITY
STATE
5 Technology Park Drive
Westford
MA
PRIMARY CONTACT
TITLE
PHONE
Kristin Ralls
Benefits Manager
978.250.7900
PHONE EXT.
ZIP CODE
01886 FAX
EMAIL
[email protected]
AFFILIATED COMPANIES Are there employees eligible for coverage working for an affiliated company? Yes If yes, please complete the following information. AFFILIATE NAME (1) STREET ADDRESS
TAX ID #
No
SEPARATE BILLING GROUP?
Yes
No
CITY
CONTACT NAME
NUMBER OF EMPLOYEES STATE
PHONE
ZIP CODE PHONE EXT.
EMAIL
What is the frequency in which you acquire new companies? If more space is needed for additional affiliates, billing groups or contacts, please provide the information requested above on the Additional Notes page.
Page 1 of 10
GENERAL PLAN AND COVERAGE INFORMATION - SECTION 2 Complete for all coverages Policy Effective Date(s) 1/1/2020
Policy Anniversary Date(s)
1/1
Active Service Definition An Employee will be considered in Active Service with the Employer on a day which is one of the Employer's scheduled work days if either of the following conditions are met. He or she is actively at work. This means the Employee is performing his or her regular occupation for the Employer on a Full-time basis, either at one of the Employer's usual places of business or at some location to which the Employer's business requires the Employee to travel. The day is a scheduled holiday, vacation day or period of Employer approved paid leave of absence, other than disability or sick leave after 7 days. An Employee is considered in Active Service on a day which is not one of the Employer's scheduled work days only if he or she was in Active Service on the preceding scheduled work day. Cigna standard is to not provide dual coverage for married couples.
Vermont and New Hampshire Laws Vermont law requires insurers to provide employers the option to cover part-time employees working at least 17.5 hours per week. Do you want to cover Vermont part-time employees? This would apply to all policies issued in Vermont including policies issued outside of Vermont covering residents of the state. Yes No If Yes, please list the policy/policies in which you are covering part-time employees:
Were these individuals included on the original census?
Yes
No If no, a new census will need to be provided.
New Hampshire law requires insurers to provide employers the option to cover part-time employees working at least 15 hours per week. Do you want to cover New Hampshire part-time employees? This would apply to all policies issued in New Hampshire including policies issued outside of New Hampshire covering residents of the state. Yes No If Yes, please list the policy/policies in which you are covering part-time employees:
Were these individuals included on the original census?
Yes
No If no, a new census will need to be provided.
Class Details - If there are classes of Employees to be covered other than Active, select the types that apply below. A census may be required. Foreign Employee Groups Retirees of the Employer Canadian Class Disabled Class (Closed) Grandfathered Class (Closed) None
Page 2 of 10
GENERAL PLAN AND COVERAGE INFORMATION - SECTION 2 (Continued) Complete for all coverages
Employee Eligibility Waiting Period No Waiting Period 1st of the month following DOH/Active Service 1st of the month after After
days from DOH/Active Service
days of Active Service
Class Specific Waiting Period - Complete only if Eligibility Waiting Period is different by class. Class 1
Class 2
No Waiting Period
No Waiting Period
1st of the month following DOH/Active Service
1st of the month following DOH/Active Service
1st of the month after
1st of the month after
After
days from DOH/Active Service
days of Active Service
After
days from DOH/Active Service
days of Active Service
Class Change Effective Date First of the month following change
Anniversary Date
Not Applicable
Rate Structure (Applicable to Critical Illness) Issue Age Attained Age - If Attained Age identify rate change effective date below First of the month following change
Anniversary Date
Takeover / Grandfather Provision Are there any individuals that will be identified under the Takeover Provision for the following products? Critical Illness:
Yes ■ No
Not applicable
The Benefit Waiting Period under this Policy will be waived The Pre-existing Condition under this Policy will be waived if the individual is covered under a Prior Plan and satisfied the Pre-existing Condition limitation Are there any amounts that will be taken over that are outside the proposed plan design (Grandfather)? Yes ■ No If Yes, please identify the details impacting Grandfathering below: Coverage amounts are different than the new plan designs Coverage amounts are above the new plan maximum Yes ■ No Not applicable Accidental Injury: The Benefit Waiting Period under this Policy will be waived The Pre-existing Condition under this Policy will be waived if the individual is covered under a Prior Plan and satisfied the Pre-existing Condition limitation ■ Yes No Not applicable Hospital Care: The Benefit Waiting Period under this Policy will be waived ■ The Pre-existing Condition under this Policy will be waived if the individual is covered under a Prior Plan and satisfied the Pre-existing Condition limitation
Page 3 of 10
GENERAL PLAN AND COVERAGE INFORMATION - SECTION 2 (Continued) Complete for all coverages Continuation of Insurance Allows insurance to be continued if an employee is no longer in active service. Premium payment is required. If applicable to your plan, please indicate maximum duration for each leave type listed. FML Leave The later of 12 weeks or the leave period required by state law (would include Military Caregiver Leave) Other: Approved Unpaid Leave of Absence End of the Month in which the leave began (standard) None
Days
Weeks
End of the Month following the month the leave began
Months
Layoff None (standard)
Days
Weeks
Months
End of the Month in which the layoff began
End of the Month following the month the layoff began
If any other Leave Types apply to your plan, please define (i.e.: Sabbatical, Military) and indicate maximum time frames.
USERRA Leave - max period Rehire Is the eligibility waiting period waived for Employees who are rehired?
Yes
No If Yes, maximum period allowed:
PLAN COVERAGE INFORMATION Plan(s) Sold
Accident Injury
Critical Illness
Hospital Care
Do you allow Employees to make election changes any time throughout the year? If yes, please advise if changes are allowed due to
Life Status Event
Yes
No
Not Applicable Annual enrollment period: 11/1- 11/30
Other Are Domestic Partners covered? Yes
Registered only (same sex)
Registered & Non-Registered (includes Same Sex & Opposite Sex)
Does Cigna need to provide you with an affidavit?
Yes
No If No, please provide Cigna with the affidavit that will be utilized.
*A Domestic Partner Affidavit must be completed by all domestic partners not registered with a state* ** Registered Domestic Partner coverage is mandated if Employees are located in California, Oregon, or Washington** No – No coverage for Registered & Non-registered Include financial dependency in definition of dependent child?
Yes
No
Not Applicable
Payroll Deduction Plan - This policy/plan is paid for entirely by employees on a post-tax basis. Includes mandatory as well as voluntary plans. Accident Injury Critical Illness Hospital Care Not Applicable Gross-Up” Plan - This policy/plan is paid for entirely by the employer; the employer cost is reported to employees on Form W-2 (IRS Letter Ruling 9708018). Accident Injury Critical Illness Hospital Care Not Applicable
Contributory Plan - This policy/plan is paid for partially by employer and employees on a post-tax basis. Select type of contribution. Percentage % Whole Dollar $ Accident Injury
Critical Illness
Hospital Care
Not Applicable
Page 4 of 10
ERISA PLAN INFORMATION - SECTION 3 Please refer to Cigna's ERISA Coverage Worksheet to determine whether a policy is issued in conjunction with ERISA. In general, any group insurance policy issued to an employer to insure employees, or to a labor union to insure union members, is subject to ERISA. Does your Company file annual ERISA reports? Yes No If Yes, please complete the following information. ERISA PLAN NAME
ASPECT SOFTWARE HEALTH AND WELFARE PLAN
Accidental Injury ERISA PLAN NUMBER(S) PLAN OF BENEFITS IS FINANCED BY PLAN YEAR ENDS
Critical Illness
Employer Employees Employer & Employees
Employer Employees Employer & Employees
Policy Year (Anniversary)
978-952-0317
Hospital Care 503
503
503
Calendar Year
ERISA PHONE NUMBER
Employer Employees Employer & Employees
Fiscal Year (provide fiscal year date)
PLAN ADMINISTRATOR Employer Other – if other, please provide Name Address AGENT FOR LEGAL PROCESS Same as Plan Administration
Other – If other, please provide
Page 5 of 10
PREMIUM AND BILLING INFORMATION - SECTION 4 Client will provide self-reported lives and volumes via the portal Client will provide ongoing eligibility data for claims via a secure connection (SA). Eligibility confirmed at time of claim. No ongoing eligibility provided. ■
Client will provide self-reported lives and volumes via Cigna Template (no portal access) Client will provide ongoing eligibility data for claims via a secure connection (SA). ■ Client will provide an ongoing eligibility and enrollment file via a file transmission (ENE) Eligibility confirmed at time of claim. No ongoing eligibility provided. Cigna will provide client with a list bill via the portal, which includes individual premium deductions The client will provide initial eligibility and enrollment data (SENE/IFG) Client will use portal to maintain eligibility and enrollment Client will provide an ongoing eligibility and enrollment file via a file transmission (ENE)
Please complete the below section for List Bill only. a.
Benefit Deduction Frequency:
Weekly = 52
Bi-Weekly = 26
Semi-Monthly = 24
Monthly = 12
Other: b.
Billing Interval if less than 12 months:
c.
Pay Day of the week: Friday
d.
Pay Day for Semi-Monthly Payroll Frequency: n/a
e.
Extra Pay Months for Bi-Weekly Payroll Frequency: January, May, July, October
f.
Employee name will be indicated on the list bill. The last 4 digits of the Employee Social Security Number will also be indicated as an additional identifier.
Please complete additional details as applicable. a. Please list each desired billing location(s) or provide via separate document: b. Will we receive payment from each billing location? c.
Will Schedule Page be turned on?
Billing Contact Name: Billing Contact Name: Billing Contact Name: Billing Contact Name:
Liazon Kristin Ralls
Yes
Yes
No, assumes one payment will be remitted from the primary billing contact.
No (Release after review and approval of initial bill) Phone: Phone: Phone: Phone:
978-250-7900
Email: Email: Email: Email:
[email protected] [email protected]
Page 6 of 10
VOLUNTARY ENROLLMENT INFORMATION – SECTION 5 Enrollment Event
Yes Event Start Date 11/4/2019
End Date* 11/15/2019
No
* Please indicate the last day the employee is allowed to sign the enrollment application.
Date Enrollment Materials needed
Printed Brochures required?
Yes
No
If Yes, please provide distribution instructions including physical address, contact name, phone number and quantity needed by class on a separate
Is it necessary to provide medical underwriting activity reporting by department or division? Yes No If yes, list desired reporting location(s) below (Cigna will assign a 4 character numeric code for each reporting location):
Note: The assigned reporting location code must be identified when an application or evidence of insurability form is submitted for processing. Cigna will supply assigned code(s). If only one reporting location, use code 0000 on application or evidence of insurability form.
PRODUCER/GENERAL AGENT COMMISSION INFORMATION - SECTION 6 Writing Agent currently appointed with Cigna Group Insurance in group situs state? Yes If applicable, our Central Licensing Department will provide appointment package for completion.
No
PRODUCER/GENERAL AGENT COMPANY NAME
COMMISSION TAX ID#
Hays Companies
41-1784898
PRODUCER NAME (WRITING AGENT)
TITLE
Eric Kasen
Broker
STREET ADDRESS
CITY
STATE
ZIP CODE
PHONE
EMAIL
80 S 8th Street, Suite 700
Minneapolis
MN
55402
617.778.5011
[email protected]
LICENSING CONTACT NAME AT PRODUCER/GENERAL AGENT OFFICE
PHONE
EMAIL
Kaitlin Henriksen
617.778.5035
[email protected]
DAY TO DAY PRODUCER CONTACT NAME
PHONE
EMAIL
Kaitlin Henriksen
617.778.5035
[email protected]
IS PRODUCER A GENERAL AGENT?
Yes
No
SUB-PRODUCER COMPANY/CONTACT NAME EMAIL
COMMISSION PAID TO Accidental Injury
PHONE
ADDRESS
Individual
■
Corporation
Critical Illness
CITY
PHONE EXT. STATE
ZIP CODE
No Commission Paid Hospital Care
Standard Blanket Standard Blanket Standard Blanket Commission Commission Commission Case Specific Case Specific Case Specific Commission 20 % Commission 20 % Commission 20 Utilize this space to identify any other commission arrangements not specified above.
%
If Split Commission complete Second Producer Information on the following page
Page 7 of 10
PRODUCER/GENERAL AGENT COMMISSION INFORMATION - SECTION 6 (Continued) SECOND PRODUCER INFORMATION
Writing Agent currently appointed with Cigna Group Insurance in group situs state?
Yes
No
SECOND PRODUCER COMPANY NAME
COMMISSION TAX ID#
Liazon - see below for Exchange Fee Information SECOND PRODUCER NAME (WRITING AGENT)
TITLE
STREET ADDRESS
CITY
PHONE
EMAIL
LICENSING CONTACT NAME AT SECOND PRODUCER OFFICE
PHONE
EMAIL
DAY TO DAY SECOND PRODUCER CONTACT NAME
PHONE
EMAIL
COMMISSION PAID TO
Individual
■
STATE
Corporation
ZIP CODE
No Commission Paid
Accidental Injury
Critical Illness
Hospital Care
Standard Blanket Commission
Standard Blanket Commission
Standard Blanket Commission
Case Specific Commission
%
Case Specific Commission
%
Case Specific Commission
%
If more space is needed for additional contact information, please attach on a separate page.
EXCHANGE SERVICE PROVIDER Yes Exchange Service Provider Fee Yes Exchange Service Provider Liazon SERVICE FEE PAYABLE TO Individual Accidental Injury 5 Service Fee
%
No No
Corporation
Critical Illness Service Fee 5
%
Hospital Care Service Fee 5
%
Page 8 of 10
POLICY/AGREEMENT APPROVAL & SIGNATURE – SECTION 7 st
Policies will be sent to the 1 Producer (if appointed) indicated in Section 8 for electronic review and approval through DocuSign, an eSignature system. Upon receipt of the eApproval, the system will send the policies to the Primary Contact in Section 1 for eSignature. If different, include the recipient’s name, title, and email address, along with the names, title, and email addresses of other contacts who wish to be copied, in the Additional Notes Section.
EMPLOYER REPRESENTATIVE SIGNATURE We acknowledge receipt of this Implementation Package, which includes documents for completion/signature and review based upon products being installed. If a proposal has been provided by the Insurance Company, we confirm the accuracy of the proposal from the insurance company named above and hereby accept the terms and conditions of the proposal and any attachments or modifications made to the proposal. We confirm the accuracy of the plan and coverage identification information contained in Section 2 and agree to the premium billing information contained in Section 6. We hereby request the issuance of insurance policies on the basis of this coverage and premium billing information. We confirm the appointment of our producer identified in Section 6 above and authorize payment of compensation as described therein. We authorize any correspondence that is directed to us, relating to any policy or agreement issued by the Insurance Company, may be disclosed to each broker of record designated by us in connection with any policy or agreement issued by the Insurance Company.
If a TPA has been designated to provide information to the Insurance Company, we authorize the Insurance Company to rely on any information provided to the Insurance Company by our TPA. We acknowledge receipt of the Privacy Notice. We hereby adopt the below-named trust as co-settlor and subscribe to that trust for the purpose of participation in these policies, which shall only cover our eligible employees, and, if applicable, retirees and dependents. We confirm the appointment of Wilmington Trust Company as Trustee, and of Life Insurance Company of North America ("LINA") as trust administrator. We appoint LINA, in its capacity as trust administrator, to represent us in dealings with the Trustee related to the insurance trust. We understand that, in the event the policy(ies) are terminated for any reason, we will cease to be a participant in the insurance trust. We understand that no benefits are provided by the trust other than the benefits described in the insurance policy(ies).
We understand that the following insurance policies are to be issued to the Group Insurance Trust for Employers in the
SERVICES 7011-8999
TRUST ISSUED POLICY TYPE
Accident Injury
7371
Industry
SIC Code
Critical Illness
Hospital Care
Ashley Scofelia
Ashley Scofelia
Authorized Employer Representative (please print name here)
Digitally signed by Ashley Scofelia Date: 2019.10.15 15:11:20 -06'00'
Authorized Employer Representative (please sign name here)
Date
Assigned Policy Number(s)
AI961246
__________________
CI961195
__________________
HC960579
__________________
Page 9 of 10
ADDITIONAL NOTES Liazon Exchange Client
Page 10 of 10