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CONTRACT 5780 Vender Agreement CLOSEDAgreement No. 5780 APPLICATION• - VISION CARE PLAN (CMI) • � VSP' Attn: Sales 3333 Quality Drive Rancho Cordova, CA 95670 (800) 216-6248 Complete all applicable questions accurately and in detail. 1 Full legal name of client as it appears on the policy: City of EI Segundo Address: 350 Main Street City: EI Segundo County: Los Angeles State: CA ZIP: 90245 Phone: Fax: Principal Contact: David Serrano Title: Director of Human Resources Phone: (310) 524-2382 Fax: E-mail: dserrano@elsegundo.org Client is headquartered in state of CA (if different state from section 1, provide physical address for client in this state) Address: City: County: State: ZIP: 2 Who should we contact with payment questions? Name: David Serrano Title: Director of Human Resources Phone: (310) 524-2382 Fax: E-mail: dserrano@elsegundo.org 3a Who should we contact with eligibility questions? Please see below for additional contacts. Name: Lauren Daniels Title: Human Resources Manager Phone: (310) 524-2335 Fax: E-mail: Idaniels@elsegundo.org 3b Does your broker need access to view/manage/update your eligibility? yes® no[] View -only access Name: Christine Kwock Title: Senior Account Executive Phone: (424) 390-0012 Fax: (610) 537-2397 E-mail: christine.kwock@usi.com 4 Who is the Benefit Administrator responsible for the overall administration of the plan (if not Principal Contact)? Name: David Serrano Title: Director of Human Resources Phone: (310) 524-2382 Fax: E-mail; If multiple benefits administrators are at other locations, attach names, addresses, emails, phone, and fax numbers. 5 What is the nature/type of your business? municipality 6 Membership information will be sent to VSP via: ❑Electronic Transfers ®Online Eligibility Management Use VSP employer portal If electronic transfer reporting OR if a third party will handle your eligibility, please provide Third Party Administrator Information. Firm; Contact: Title: Address: City: County: State: ZkP: Phone: Fax: E-mail: Additional eligibility contacts: Lauren Daniels, Human Resources Manager, E: Ldaniels@eisegundo.org, P: (310) 524-2335 Dana Hang, Senior Human Resources Analyst, E: Dhang@elsegundo.org, P: (310) 524-2328 Leslie Campbell, Human Resources Analyst, E: Lcampbell@eisegundo.org, P: (310) 524-2336 Iii .'n i" :1iijpIIi'P�i�rll i,l �i''ll� QL ige I DF 5 Agreement No. 5780 In conjunction with health plan industry practices when providing electronic eligibility, VSP requests clients to send dependent eligibility information to VSP. This would include providing the covered dependent's full name, date of birth, and relationship to the employee/member. Dependents will be reported as a dependent underthe employee's ID number. Will dependent information be sent to VSP for eligibility purposes? Dyes ❑no If no, please explain: Employers without Internet access for making membership updates will be contacted by VSP to review other options. 7a Is a COBRA division is required? ®yes ❑no 7b Names of additional divisions that require separate billing. Retiree Address of additional divisions if applicable. IMPORTANT: Separate divisions will be billed on separate invoices (If multiple divisions are needed, attach list of division names, contact names, address, email, phone, and fax numbers): Billing address (if different than Client address): same as client City: County: State: ZIP: Phone: Fax.: E-mail: If Self -Funded Program, do claims billings and administrative fee billings go to the same person? Oyes Ono If no, please supply contact, title, address, phone, and fax number for each type of billing. 8 Number of employees eligible for benefits: Does this represent the total number of employees in the company? ❑yes ®no ❑ total number: Do you have an employee population outside of the US? ❑yes ®no If yes, what country Do you provide benefits to your retiree population? ®yes ❑no 9 Dependents: Eligible dependents are the covered employee's spouse and dependent children until the end of the month that they reach their (26th] birthday, or the end of the month that they reach their [ ] birthday, if attending school full time. (Includes an unmarried child if incapable of self-support because of physical or mental incapacity that commenced prior to reaching the above age) Dependents other than employee's spouse & children: ❑ domestic partners (all) ® domestic partner's children ® domestic partners (same sex only) ❑ parents (IRS qualified) Domestic Partners: City allows for only registered domestic partners and their dependents POLICY DETAILS The rates listed must support the plan design and benefit selected and must meet all eligibility requirements. Please refer to your VSP-provided rate sheet for details or contact your VSP Account Executive. Any discrepancies may preclude acceptance by VSP. 10 Benefit Year (select one) ®Service Year (from last date of. service) ❑Calendar Year (IMPORTANT: only available if policy effective date and renewal date is January 151) 11 Plan Type (select one): ❑Signature Plan ®Choice Plan ❑Exam Plus ❑Exam Plus w/ Allowances 12 Is vision benefit: ®Core ®Voluntary ❑Packaged with medical and/or dental Elected Officials (City Clerk, City Treasurer, and Council) Executive Classes Management/Confidential Supervisory and Professional City Employees kssoctation Plreflghter5' Association Police Officer Association (Officers and Sergeants) Paid for Officials and eligible dependents Paid for by City for employee and eligible dependents Paid for by City For employee and eligible dependents Paid for by City for employee and eligible dependents $135/month City cont16ba,rVorus� ff. r n iploye;e ar '�,eilgib ';epen�denu,, for dental and vision $135/month 'City r; nRribaatirarrs for errrployec and eligible dependent; For dental find w .sd+ n Police Management Association (Captains and Lieutenants) Paid for by City for employee and eligible dependents ` —rsion 7 Police Support Services Employees Association $135/month City contributions for employee and eligible dependents for dental and vision Retirees (Certain R3'raups) 100% Retiree Pard Agreement No. 5780 If Voluntary (vision is included as a stand-alone menu item in a list of benefits to choose from.): Please refer to table on prior page. Employer contribution percentage: for employee: % for dependent: Voluntary Participation Structure: *A minimum number of enrolled employees may apply. ❑Exam w/Voluntary Materials* ❑Voluntary Pool 0-24% employer contribution* ❑Voluntary Pool 25% or more employer contribution* []Core Employee/Voluntary Dependent Coverage* If Core Plus Options (group provides a basic level of vision coverage to all employees with an option for the employee to buy up or enhance the benefit): Employer contribution percentage: for employee: % for dependent: If Packaged (vision is tied to which of the following benefits: ❑medical ❑dental 13 Frequency of Service (select one); []A(12/24/24) (IMPORTANT: 12/24/24 is not available on voluntary plans) ®B (12/12/24) ❑C (12/12/12) ❑Other: Copayment ❑Split co -payment: $ exam / $ eyewear OR ®Total co -payment: $10 (applies to exam and eyewear) 14 a Elective Contact Lens (Allowance): ❑$120 ❑$130 ❑$140 ®$150 0$180 ❑other: $ Frame (Retail Frame Allowance): ❑$120 ❑$130 ❑$140 ®$150 ❑$180 ❑other: $ 14 b Client has purchased Enhancements: ❑yes ❑no ❑Scratch Coating ❑Anti -Reflective Coating ❑Progressive Lenses ❑Photochromic /Tint 14c Client has purchased Specialty Care: yes® no❑ SunCare ❑Covered Contact Lenses ❑ProTec Safety ❑Second Pair of Glasses ❑Computer Vision Care ❑Vision Therapy [-]Preferred Laser VisionCare (available on a self-funded basis only to clients with 200+ enrolled employees) 15 Requested effective date (The effective date should not precede the date VSP receives this application.) This policy will become effective on the first day of [ September ] (month) [ 2019 ] (year), provided that all of the following has been completed prior to this effective date: A. VSP has received and accepted this application. B. VSP has received and accepted membership, including the required information of all employees that will be covered under this policy showing name, member ID, and dependents, if applicable. 16 Schedule A Information: Fiscal Year [ ]through [ ]• N/A Schedule A will be sent to the person named as the principal contact. A copy of the report may also be sent to your broker and/or your third party administrator. 17 Do you currently have vision coverage: g • ®yes Ono If yes, current vision plan carrier: VSP If current carrier is VSP, please provide client name:Teamsters MISC. Security Trust 18 For fully -insured programs (VSP will bill for the first month's premium) Rates $ 16.25 IMPORTANT: Sold rates are required to process this application 19 For self-insured programs, Administrative Fee: N/A Administrative fee: or Percentage of claims: Composite rate will be effective 9/1/2019 and will be guaranteed until 1/1/2022. (28 month rate guarantee) Effective 9/1/2019, employees & dependents will start with new frequencies of services (exams, frames, lenses). Initial census will include empioyees/dependent information to follow upon completion of open enrollment. pac,e 3 :; _ Agreement No. 5780 AGREEMENT The undersigned client hereby applies for vision care coverage through VSP. It is understood that: A. All future employees will be covered when they become eligible or offered VSP coverage if voluntary. B. Coverage will terminate for an employee on the last day of the month in which employment terminates. C. Member past service for clients previously covered by VSP will carry over and remain in force. D. Any non-VSP-created information outlining coverage or plan details must be reviewed by VSP prior to distribution to members. E. This agreement will continue in force 24 months from the effective date. Rates are based on the assumption that VSP will receive these amounts over the full plan term, APP As TO FORM: This application signed this (day) of September (month) of [ 2019 (year). �rfti f - FrIC11- Firm/Organization: City of El Segundo CITY ATTORNEYS A Name: TitlCi e: C.z Signature. Any person who knowingly and with intent to injure, defraud, or deceive any insurer, files a statement of clulm or an ap) false, incomplete or misleading information. Is guilty of ofelony of the third degree, o. SP I Ef I"To B R 0 K E R The broker/consultant indicated below is hereby designated Broker of Record by the above signed employer. Broker of Record Legal Firm Name: USI Insurance Services LLC Address: 21250 Hawthorne Blvd., Ste. 600 City: Torrance County- Los Angeles State: CA ZIP: 90503 Licensed Producer's Name: Gary L. Delaney Title: Senior Vice President Phone: (424) 390-0010 Fax: (610) 537-2397 E-mail: gary.delaney@usi.com Additional contact name: Christine Kwock Phone; (424) 390-0012 E-mail; christine.kwock@usi.com This application signed this I I (day) of [ September ] (month) of [ 2019 (year). Signature of state -licensed agent: License #: Please include a copy of agent/broker license, if not currently an file with VSP, I COMMISSION CHECKS PAYABLE TO Commission Checks Payable to. ®Firm Name ❑Contact Name MNot Paid Taxpayer 10:13-3771734 r7Same as licensed producer listed above ®Other: Legal Firm Name: USI Insurance Services LLC Address: 21250 Hawthorne Blvd., Ste. 600 City: Torrance County: Los Angeles Phone: (424) 390-0000 version 20170301 v.1 Fax: (610) 537-2397 client application — (CMI) ®Corporation Mindependent State: CA ZIP: 90503 E-mail: stella.bonaventura@usi.com page 4 of 5 224 Agreement No. 5780 BROKER/CONSULTANT LISTED BELOW TO RECEIVE CORRESPONDENCE Same as licensed producer listed above ©Other: Legal Firm Name: USI Insurance Services LLC State -licensed Agent / Contact Name: Christine Kwock License M Address: 21250 Hawthorne Blvd., Ste. 600 City: Torrance County: Los Angeles State: CA ZIP: 90503 Phone: (424) 390-0012 Fax: (610) 537-2397 E-mail: christine.kwock@usi.com If additional broker/consultant is to have access to this account copy page and specify commission percentage split (if applicable). Include copy of agent/broker license if not currently on file with VSP.