Okaloosa County BOCC — October 21, 2014 — Symetra - Final Payment Request — reading text

CONTRACT CLOSE-OUT CHECKLIST (To Be Prepared by the Contracts and Lease Coordinator) DATE: 10/7/2014 TO: Contracts & Grants Manager, Finance Department Contracts & Grants Office SUBJECT: Contract No. C12-1976-RM MANAGING DEPARTMENT: RISK MANAGEMENT CONTRACTOR'S NAME: SYMETRA PROJECT TITLE: EMPLOYEE LIFE & LTD The attached has met the final payment contract requirement in subject contract. Yes No 1 Final Invoice Xl O 2. Completed Contract/Lease Payment Approval Form Xx] O 3. Close-Out Documents Yes No N/A a. Signed Release of Lien O O Xl b. Proof of Completion Advertisement im im X c. Certificate of Insurance im im) d. Consent of Surety to Final Payment im) oO xX e. Proof of Performance/Payment Bond oO O XK Continuation 12 Months Following Final Payment Yes No 4, Agenda Request x O 5. Joanne Kublik-Coniracts and Lease oordinator DATE CONTRACT/LEASE PAYMENT APPROVAL FORM COMPLETE AND FORWARD TO THE NEXT DEPARTMENT COMPLETED BY DEPARTMENT DATE; 09/25/2014 VENDOR NAME: Symetra VENDOR #; 21300005 CONTRACT/LEASE#; ©12-1976 RM TASK COUNTY/FEMA INVOICE # ORDER # PROJECT # DEPARTMENT g| ACCOUNT? AMOUNTS (If Applicable) {Uf Applicable) September 2014 Sept 2014 5102 545050 $ 3,865.41 5102 545051 $ 16,948.81 5102 545060 $ 3,894.66 5102 545061 $ 745.92 TOTAL $ 25,454.80 APPROVED FOR PROGRESS PAYMENT (please sign, as applicable and date) CONTRACTOR'S ENGINEER/ARCHITECT/PROJECT MANAGER: COUNTY SUPERVISOR/PROJECT MANAGER: , Loa DEPARTMENT DIRECTOR: O\<K, Lt jaca Q NA “4 ° CONTRACTS & GRANT MANAGER: COUNTY ADMINISTRATOR: (Payments>$25,000.) DATE: DATE: lo| y 14 DATE: jo | \ Let DATE: DATE: FINAL PAYMENT FINAL PAYMENT ves lvol_| (If "Yes", forward to Purchasing Services Coordinator for Close-Out) DATE: PURCHASING DIRECTOR: (Per Initial Agreement) DATE: “- SDB 74 Sf CONTRACTS & GRANTS MANAGER: . (All Contracts) DATE: heft, COUNTY ADMINISTRATOR APPROVAL: { . (Per Initial Agreement) DATE: BOARD APPROVAL: (Per Initial Agreement) COMPLETED BY FINANCE - ACCOUNTS PAYABLE ONLY FISCAL YEAR: DATE RECEIVED: REVIEWD BY: 10 pages were removed from this scanned file as they contain benefit information that is sensitive in nature. The originals of these documents will be provided to Ms. Teresa Ward and the Finance Department for final payment. If you have any questions, please contact GinNeal McVay, Human Resources Manager at 850-689-5870. AM eal 4h Medan . Policy Number 01-016209-00 SYM ETR A Client ID LE-000303 Billing Period Sept 2014 BENEFITS DEPARTMENT EMPLOYER'S SELF ADMINISTERED BILLING STATEMENT MAIL TO: Okaloosa County Board of Commissioners POLICYHOLDER: Attn: Sue Barrow Okaloosa County Board of Commissioners 601 A. North Pearl Street, Suite 204 Crestview, FL 32536 Please calculate premium and fees due and submit your payment via ACH, wire or check in the enclosed envelope. Number of Lives Volume Rate Premium/Fees Basic Life CL 1,2 703 17,575,000.00] X 0.1590 / 1,000 S 2,794.43 Basic AD&D CL 1,2 703 17,575,000.00] X 0.0250 / 1,000 $ 439.38 Supp Life CL 1,2 301.00 32,170,000.00 | X *See remarks S 13,114.77 Supp AD&D CL 1,2 226 24,517,500.00| X 0.0200 / 1,000 $ 490.35 Supp Spouse Life CL 1,2 96.00 2,997,500.00 | X *See remarks 5 1,479.20 Supp Child Life CL 1,2 72 602,500.00} X 0.1000 / 1,000 S 60.25 LTD CL 1,2 703 X| 4.6200 / member / month S 3,247.86 Buy-Up Disability CL 1,1 188 X| 3.3600 / member / month $ 631.68 * Coverage is step rated by age band. See Admin Kit or Call toll free number. Total Premium/Fees S 22,257.91 Remarks and Adjustment Explanation: Adjustments S 243.64 Current Account Balance as of Gross Premium/Fees Due $22,014.27 Credit taken for over age dependent life. Make Check Payable to: Symetra Life Insurance Company Prepared By Return Statement & Symetra Life Insurance Company Date Premium/Fees to: Benefit Accounting Services C/O Wells Fargo Last Payment Received PO Box 1491 Minneapolis MN 55480-1491 Coverages or Rates listed incorrectly? Address Change? Call 1-800-426-7784 LG-12024 6/12 Symetra Life Insurance Company - Group Division - 777 108th Ave NE - Suite 1200, Bellevue, WA 98004 - www.symetra.com Mailing Address: PO Box 34690 - Seattle, WA 98124-1690 - Phone (800) 426-1690 - TTY/TDD (800) 833-6388 Okaloosa County 01-016209-00 Employee Supplemental Life Worksheet “Please enter total headcount and Inforce for each age band Age Band Headcount Inforce Rate Premium Under 25 | y | | 0.0700 - 25 to 29 | Oo] | 0.0700 - 30 to 34 Oa 0.00} 0:0800 - 35 to 39 | Ok | 0.1100 - 40 to 44 | Do | 0.1600 - 45 to 49 | 1 6 300,000.00] 0.2900 87.00 50 to 54 | ‘a 725,000.00) 0.4500 326.25 55 to 59 | 2 250,000.00} 0.6100 152.50 60 to 64 | 4‘ 975,000.00)" 4.0200 994.50 65 to 69 1 32,500.00)) 4.5900 51.68 70 to 74 | ee | 2.5700 - 75 + | o | 5.1200 - Grand Total: 13 2282500 1,611.93 Okaloosa County 01-016209-00 Employee Supplemental Life Worksheet *Please enter total headcount and Inforce for each age band Age Band Headcount Inforce Rate Premium Under 25 | | 175,000.00), 0.0700 12.25 25 to 29 | 14 1,300,000.00}) 0.0700 91.00 30 to 34 | 12, 1,400,000.00]}) 00800 112.00 35 to 39 | 344] ——_-3,850,000.00])) 0.4100 423.50 40 to 44 | 31 4,275,000.00] 0.1600 684.00 45 to 49 | 48) | 5,525,000.00}) 0.2900 1,602.25 50 to 54 | 54) | —_-5,650,000.00)) 0.4500 2,542.50 55 to 59 i 55 al 4,975,000.00]) 016100 3,034.75 60 to 64 | 29) | 2,525,000.00]" 10200 2,575:50 65 to 69 | 5 123,500.00) 1.5900 196.37 70 to 74 | nu OUCdéd 89,000.00}, 2.5700 228.73 75+ | fo __| 5.1200 - Grand Total: 288 29887500 11,502.85 Okaloosa County 01-016209-00 Employee Supplemental Spouse Life Worksheet *“Please enter total headcount and Inforce for each age band Age Band Headcount Rate Premium Under 25 | yD | | 0.0700 - 25 to 29 | | | 0.0700 - 30 to 34 | mH | | 0.0800 - 35 to 39 | laa | 0.1100 - 40 to 44 | jee | | 0.1600 : 45 to 49 | a 6OC*d@éd 50,000.00}, 0.2900 14.50 50 to 54 | 2 50,000.00) 04500 22.50 55 to 59 | 1 25,000.00) 016100 15.25 60 to 64 | 4 150,000.00] 1.0200 153.00 65 to 69 | D | | 1.5900 - 70 to 74 | | | 2.5700 = 75+ | Y | | 5.1200 - Grand Total: 8 275000 205.25 Okaloosa County 01-016209-00 Employee Supplemental Spouse Life Worksheet **Please enter total headcount and Inforce for each age band Age Band Under 25 25 to 29 30 to 34 35 to 39 40 to 44 45 to 49 50 to 54 55 to 59 60 to 64 65 to 69 70 to 74 75 + Grand Total: Headcount Inforce Rate Premium | | | 0.0700 - | 1| 100,000.00}, 0.0700 7.00 | 4| 125,000.00), 00800 10.00 i 8} 175,000.00}, 0.1100 19.25 7 175,000.00) O:1600 28.00 11] 425,000.00) 02900 123.25 | 22| 700,000.00] 0.4500 315.00 i 23] 700,000.00] 0:6100 427.00 | Hn |€6D 312,500.00] 1.0200 318.75 | | | 1.5900 - | 1] 10,000.00) 2.5700 25.70 | | | 5.1200 - 88 2722500 1,273.95 2 Policy Number 01-016209-00 SYMETRA RETIREMENT | SEMEFITS | LiFe Client ID LE-000303 Billing Period September 2014 Please Remit by September 30, 2014 BENEFITS DEPARTMENT EMPLOYER'S SELF ADMINISTERED BILLING STATEMENT MAIL TO: Okaloosa County Board of Commissioners POLICYHOLDER: Attn: Sue Barrow Okaloosa County Board of Commissioners 601 A. North Pearl Street, Suite 204 Crestview, FL 32536 Please calculate premium and fees due and submit your payment via ACH, wire or check in the enclosed envelope. Number of Lives Volume Rate Premium/Fees Basic Life CL 1,2 38 882,500.00] X 0.1590 / 1,000 S 140.32 Basic AD&D CL 1,2 38 882,500.00] X 0.0250 / 1,000 S 22.06 Supp Life CL 1,2 16.00 2,050,000.00 } X *See remarks S 808.50 Supp AD&D CL 1,2 5 875,000.00} X 0.0200 / 1,000 S 17.50 Supp Spouse Life CL 1,2 8.00 350,000.00 | X *See remarks S 180.50 Supp Child Life CL 1,2 5 45,000.00] X 0.1000 / 1,000 5 4.50 LTD CL 1,2 38 xX 4.6200 / member / month S$ 175.56 Buy-Up Disability CL 1,1 9 X] 3.3600 7 member / month $ 30.24 * Coverage is step rated by age band. See Admin Kit or Call toll free number. Total Premium/Fees $ 1,379.18 Remarks and Adjustment Explanation: Adjustments S (4.58) Credit of $8.00 for ineligible spouse dependent coverage Current Account Balance elected for July and August 2014 billing. (Mary Henderson) as of Charge for August 2014 Basic Life AD&D & buy up LTD for Gross Premium/Fees Due $ 1,383.76 Darlene Drury as transfer from OCTC for $12.58 Net adjustment of $4.58. Make Check Payable to: Symetra Life Insurance Company Prepared By Return Statement & Symetra Life Insurance Company Date Premium/Fees to: Benefit Accounting Services C/O Wells Fargo Last Payment Received PO Box 1491 Minneapolis MN 55480-1491 Coverages or Rates listed incorrectly? Address Change? Call 1-800-426-7784 LG-12024 6/12 Symetra Life Insurance Company : Group Division - 777 108th Ave NE - Suite 1200, Bellevue, WA 98004 - www.symetra.com Mailing Address: PO Box 34690 - Seattle, WA 98124-1690 - Phone (800) 426-1690 - TTY/TDD (800) 833-6388 Okaloosa County 01-016209-00 Employee Supplemental Life Worksheet **Please enter total headcount and Inforce for each age band Age Band Under 25 25 to 29 30 to 34 35 to 39 40 to 44 45 to 49 50 to 54 55 to 59 60 to 64 65 to 69 70 to 74 (EE? Grand Total: Headcount Inforce Rate Premium | | 0.0700 | | 0.0700 I | 0.0800 | | 0.1100 | 0.1600 | | 0.2900 @ 300,000.00] 014500 | 275,000.00] 16100 | | 1.0200 | 1.5900 | | 2.5700 | | 5.1200 575000 135.00 167.75 302.75 Okaloosa County 01-016209-00 Employee Supplemental Life Worksheet **Please enter total headcount and Inforce for each age band Age Band Headcount Inforce Rate Premium Under 25 | | | 0.0700 - 25 to 29 | || | 0.0700 - 30 to 34 | 1 300,000.00)) 0,0800 24.00 35 to 39 | 1 175,000.00) 04100 19.25 40 to 44 | 24 175,000.00}, 0.1600 28.00 45 to 49 2] | 350,000.00] 0.2900 101.50 50 to 54 1 50,000.00}, 04500 22.50 55 to 59 3 300,000.00}) 0.6100 183.00 60 to 64 { 3 125,000.00} 4.0200 127.50 65 to 69 | | | 1.5900 - 70 to 74 | eee] | 2.5700 - (ee le | | 5.1200 - Grand Total: 13 1475000 505.75 Okaloosa County 01-016209-00 Employee Supplemental Spouse Life Worksheet **Please enter total headcount and Inforce for each age band Age Band Headcount Rate Premium Under 25 | | | 0.0700 25 to 29 | } _| 0.0700 30 to 34 } | 0.0800 35 to 39 | | 0.1100 40 to 44 -| 0.1600 45 to 49 | | 0.2900 50 to 54 | 1| 100,000.00) 0.4500 55 to 59 | 2| 125,000.00), 016100 60 to 64 | | | 1.0200 65 to 69 } | 1.5900 70 to 74 } ] 2.5700 15 | | 5.1200 Grand Total: 3 225000 45.00 76.25 121.29 Okaloosa County 01-016209-00 Employee Supplemental Spouse Life Worksheet *“Please enter total headcount and Inforce for each age band Age Band Under 25 25 to 29 30 to 34 35 to 39 40 to 44 45 to 49 50 to 54 55 to 59 60 to 64 65 to 69 70 to 74 15 + Grand Total: Headcount Inforce Rate | 0.0700 | 0.0700 | 0.0800 | 0.1100 25,000.00), 01600 50,000.00}, 0.2900 | 0.4500 25,000.00) Oie400 25,000.00}, 1.0200 | 1.5900 | 2.5700 | 5.1200 125000 Premium 4.00 14.50 15.25 25.50 59.25 SYMETRA RETIREMENT | BENEFITS | LIFE Policy Number Client ID Billing Period 01-016209-00 LE-000303 September 2014 BENEFITS DEPARTMENT EMPLOYER'S SELF ADMINISTERED BILLING STATEMENT —— a some eure MAIL TO: Okaloosa County Board of Commissioners Attn: Sue Barrow 601 A. North Pearl Street, Suite 204 Crestview, FL 32536 POLICYHOLDER: Okaloosa County Board of Commissioners Please calculate premium ai nd fees due and submit your payment a via ACH, wire or check in the enclosed envelope. | Number of Lives Volume Rate Premium/Fees Basic Life CL 1,2 101 2,525,000.00} X 0.1590 / 1,000 S 401.48 Basic AD&D CL 1,2 101 2,525,000.00] X 0.0250 / 1,000 S 63.13 Supp Life CL 1,2 31.00 4,425,000.00 | X *See remarks S 875.00 Supp AD&D CL 1,2 10 1,625,000.00] X 0.0200 / 1,000 5 32.50 Supp Spouse Life CL 1,2 14.00 362,500.00 | X *See remarks S 122.13 Supp Child Life CL 1,2 17 152,500.00] X 0.1000 / 1,000 S 15.25 LTD CL 1,2 101 X| 4.6200 /member/ month |$ 466.62 Buy-Up Disability CL 1,1 24 xX 3.3600 / member / month S$ 80.64 * Coverage is step rated by age band. See Admin Kit or Call toll free number. Total Premium/Fees Ss 2,056.74 Remarks and Adjustment