CONTRACT 6193 Vender AgreementCity of El Segundo Vdr. Agr. No. 6193
CUSTOMER AGREEMENT
City of El Segundo
350 Main Street
EL SEGUNDO, CA 90245
Sep 15, 2021
Dear
i Aw
Thank you for choosing a benefits program from Metropolitan Life Insurance Company ("MetLife") and the
MetLife family of Companies. We are excited to be providing benefits for City of El Segundo employees. To
get started, please sign a copy of this letter below.
The benefits you have chosen for your Dental, Basic Life with AD&D, Supplemental Life with AD&D, Long
Term Disability, Dental Benefits are listed in the schedules already provided to you. If your MetLife benefit
offerings change, we will reflect those changes in a new schedule.
MetLife will offer the benefits listed on the attached schedules ("MetLife Benefits") to all eligible
individuals. Individuals who obtain benefits are referred to as "Participants".
2. For each of the MetLife Benefits listed on the attached schedule, MetLife will provide as applicable either:
a group insurance policy and insurance certificates; individually underwritten insurance policies; a
detailed benefits schedule; or one or more administrative agreements. These documents will detail the
benefits provided, costs, effective date, and other important terms. Nothing in this letter changes any of
the terms of the group or individual insurance policies, certificates or other applicable administrative
agreements.
3. MetLife will comply with all laws applicable to MetLife's activities in connection with the MetLife Benefits.
4. MetLife will provide information and materials that eligible individuals need to understand the MetLife
Benefits.
S. MetLife will process eligibility information and payroll deductions in accordance with MetLife's policies
and procedures for each MetLife Benefit. MetLife will be responsible for all pricing and individual
underwriting decisions.
6. MetLife will provide account management services to City of El Segundo and customer service to eligible
individuals.
7. MetLife will treat all non-public personal information about eligible individuals in a confidential manner
and in accordance with all applicable laws.
8. Participants no longer employed by City of El Segundo (and where applicable, their dependents) may
continue certain benefits with MetLife in accordance with MetLife's policies and procedures.
(continued)
City of El Segundo Vdr. Agr. No. 6193
City of El Segundo'S RESPONSIBILITIES:
1. City of El Segundo will communicate the MetLife Benefits to all eligible individuals and will distribute
enrollment materials. City of El Segundo will provide MetLife with full access to the eligible population.
City of El Segundo will perform its administrative obligations to the fullest extent to drive maximum
participation in MetLife Benefits by all eligible individuals.
2. City of El Segundo will process enrollments and will report to MetLife the identity of all Participants. For
certain MetLife Benefits, MetLife requires that City of El Segundo will provide a list of all Eligible
Employees and provide regular updates thereto. City of El Segundo will provide this if required to do so.
MetLife and City of El Segundo will agree upon the timing and format of this enrollment information.
3. City of El Segundo will not use the name or Brand of MetLife or create or distribute materials regarding
the MetLife Benefits without MetLife's approval.
4. City of El Segundo will comply with all laws applicable to City of El Segundo's activities in connection with
the MetLife Benefits.
5. Where Participants contribute to the cost of the MetLife Benefits, City of El Segundo will provide payroll
deductions for amounts due in connection with the MetLife Benefits and will remit payments to MetLife.
6. City of El Segundo will be responsible for any filings required by the Department of Labor or other
Federal or State agencies. Upon request, MetLife will provide applicable information necessary to make
such filings.
7. If City of El Segundo is represented by an insurance agent or broker for purposes of a MetLife Benefit,
City of El Segundo agrees to inform MetLife of any change in its insurance agent or broker.
We look forward to serving your benefit needs! If the terms of this letter are acceptable to City of El Segundo,
please sign below.
Very Truly Yours,
METROPOLITAN LIFE INSURANCE COMPANY
By
Executive Vice President
Title
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Accepted and Agreed to:
City of El Segundo
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City of El Segundo Vdr. Agr. No. 6193
Group, Voluntary & Worksite Benefits
Metropolitan Life Insurance Company
200 Park Avenue
New York, NY 10166
Statement of Responsibility
MetLife
MetLife will be responsible to the group policyholder for the performance of its administrative obligations under the group
policy, this agreement and any other written agreement between MetLife and the group policyholder. If MetLife uses a
third party in connection with any of MetLife's administrative obligations, MetLife will remain responsible to the group
policyholder for the performance by the third party of those administrative obligations. The third party will work under the
control and direction of Metlife and Metlife will be solely responsible for the acts, errors and omissions of the third party.
The group policyholder will be responsible to MetLife for the performance of its administrative obligations under the group
policy, this agreement and any other written agreement between MetLife and the group policyholder. If the group
policyholder uses a third party in connection with any of the group policyholder's administrative obligations, the group
policyholder will remain responsible to MetLife for the performance by the third party of those administrative obligations.
The third party will work under the control and the direction of the group policyholder and the group policyholder will be
solely responsible for the acts, errors and omissions of the third party.
To be completed by Policyholder:
( pry (Title of a horized kepresii five)
Na a Authorized Re r entative)
t �.w . IC City of El Segundo
(St na lire of Policyholder Authorized Representative) (Group Policyholder Name)
Signed at:
(City) (State) Date(MM/DD/YYYY)
To be completed by Metropolitan Life Insurance Company:
James W. Reid
Executive Vice President
Group, Voluntary & Worksite Benefits
APPROV .,C TO FORM.
CITYd `II EY
Date(MM/DD/YYYY)
Y
w� � undo SoR (4/15)
Group Voluntary & Worksite Benefits
City of El Segundo Vdr. Agr. No. 6193
SERVICE FEE DISCLOSURE AND AUTHORIZATION
City of El Segundo — Group Insurance Coverages
MetLife enters into arrangements concerning the sale, servicing and/or renewal of MetLife
group insurance and certain other group -related products ("Products") with brokers, agents,
consultants, third -party administrators, general agents, associations, and other parties that may
participate in the sale, servicing and/or renewal of such Products (each an "Intermediary").
MetLife may pay your Intermediary compensation, which may include base compensation,
supplemental compensation, and/or service fees, where applicable.
MetLife requires a customer's written authorization in order to pay service fees to an
Intermediary in relation to that customer's Products. Below is a description of specific service
fees that MetLife is prepared to pay to your Intermediary, Burnham Benefits Insurance Services
("Burnham Benefits"), for its services in connection with your MetLife Products:
1. Nature and scope of services: marketing, communication services, enrollment support
and processing of applications/enrollments for MetLife insurance products.
Service fee amount: 3% of premium received and earned by MetLife, up to a maximum
of $50,000 per year. (Note: The cost of this fee does not affect your MetLife group
insurance rates. Your premium rates will be the same whether MetLife provides these
administrative services or Burnham Benefits provides them.)
2. City of El Segundo agrees that the above services shall be provided by, and payment
will be made to Burnham Benefits.
3. For MetLife group insurance products, MetLife can provide the same services as those
to be performed by Burnham Benefits. MetLife cannot provide these services with
respect to the insurance products issued by other insurers.
By signing below, you are representing to MetLife that you are an authorized representative
of City of El Segundo with authority to complete this form and that you authorize MetLife to
pay the service fees described above to Burnham Benefits. If you have questions, please
contact Chris Decker (cdecker@metlife.com) at (415) 957-4158.
Thank you for your prompt attention to this matter.
To be filled in by Customer:
Customer Name:
Signature:
City of El Segundo
j
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Printed Name:
Title:
Date.
Z�
SF Authorization, Burnham Benefits, 10.19.18
APPR,IJ
S TO FORM:
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City of El Segundo Vdr. Agr. No. 6193
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Metropolitan Life Insurance Company
200 Park Avenue, New York, New York
APPLICATION FOR GROUP INSURANCE
The applicant named below is applying for Group Insurance to provide coverage for the class(es) of persons specified
below.
APPLICANT DATA
1. Full legal name of Applicant: City of El Segundo
2. Address: 350 Main Street
(the "Policyholder")
City EL SEGUNDO State CA Zip 90245
EFFECTIVE DATE
The effective date of the applied for group insurance will be 01/01/2022, subject to MetLife's acceptance of this application
and the Applicant's payment of the Premium due on or before such date.
SITUS
Group Policy forms will be issued for delivery in and governed by the laws of CALIFORNIA
COVERAGE DATA
Employees / Members
Long Term Disability
Supplemental Life with AD&D
Basic Life with AD&D
Dental
PREMIUM DATA
Dependents
Supplemental Life with AD&D
Dental
Premiums will be paid: ® Monthly Quarterly Annually Other
Attached is an advance payment of: $ 0
AGREEMENT
The Applicant signing below agrees to accept the terms and provisions of all Group Policy forms issued pursuant to this
application; including all Exhibits, amendments and endorsements, if any.
Fraud Warning. Any person who knowingly and with intent to defraud any insurance company or other person files an
application for insurance or statement of claim containing any materially false information, or conceals for the purpose of
misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and
subjects such person to criminal and civil penalties.
Signatureof Applicant'sDate:
,tat Date: �7
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Name of Authorized Repress five ` ��i L,L
Title of Authorized Repres t Zve &r
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Applicant's Signature ��� ��q �� SCow WAi L
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III. of El Qe. urdo
GAPP13-02 CA
City of El Segundo Vdr. Agr. No. 6193
Signature of Licensed MetLife Agent or Resident Agent as required by law
Agent's State License No.
Date: 09/15/2021
Name of Agent: Ben Fincher
Agent's Signature Beiv Fj*whe -
GAPP13-02 CA
City of El Segundo Vdr. Agr. No. 6193
M te- t Li fe
Benefits provided by SafeGuard Health Plans, Inc.,
a Metlife company
200 Park Avenue, New York, New York 10166
APPLICATION FOR GROUP DENTAL BENEFITS
The applicant named below is applying for a Group Contract to provide dental benefits for the persons specified below.
APPLICANT DATA
1. Full legal name of Applicant: City of El Segundo
2. Address: 350 Main Street
City EL SEGUNDO State CA Zip 90245
CONTRACT EFFECTIVE DATE
The Group Contract's effective date will be 01/01/2022, subject to MetLife's acceptance of this application.
CONTRACT SITUS
The Group Contract will be issued for delivery in and governed by the laws of CALIFORNIA
COVERAGE DATA
Employees / Members
Dental Benefits
PREPAYMENT FEE DATA
IDental Benefits
Prepayment Fees will be paid: ® Monthly Quarterly Annually Other:
Attached is an advance payment of: $ 0
AGREEMENT
Dependents
The Applicant signing below agrees to accept the terms and provisions of the Group Contract, including its Exhibits,
amendments and endorsements, if any.
Fraud Warning. Any person who knowingly and with intent to defraud any insurance company or other person files an
application or statement of claim containing any materially false information, or conceals for the purpose of misleading,
information concerning any material fact thereto commits a fraudulent act, which is a crime and subjects such person to
criminal and civil penalties.
Signature of Applicant's Legal Representative
Signed at: City 1;55'e , a i w C� p State C P, Date: [U .-tz z
Name of Legal Representative "C o I (�-
Title of Legal Representati e C t. f e "—
Applicant's Signature L
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(SafeGuard Representative)
TO FORM.
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Assistant Vice President Isaac Torres
(Representative's title) (Print Name of Representative)
APP-GP10-DHMO CA
City of El Segundo Vdr. Agr. No. 6193
HIPAA Request
If you wish to include in your booklet certificate the HIPAA privacy language shown on the specimen "Sample Dental and/or
Vision Booklet Certificate/SPD Language" provided to you by MetLife, please answer the following questions, sign, and return this
form to your MetLife Sales Office.
A. Are there employees of the Plan Sponsor that may access PHI (Protected Health Information) provided by the Plan? If there
are, please provide their title(s) or other identifiers below.
PLEASE DO NOT PROVIDE THEIR NAMES; ONLY TITLE OR OTHER IDENTIFIER.
Title Human Resources Director Title Human Resources Manage Title Sr. Human Resources Analyst
Title
Title
Title
B. Should the term "Privacy Officer" be included in Section III. (c) "Sharing of PHI with the Plan Sponsor" of the Dental and/or
Vision Plan Document?
® Yes ❑ No
C. Should Section IV. "Participant's Rights" be included in the Dental and/or Vision Plan Document? (This is an optional section.)
® Yes ❑ No
D. Should Section V. "Privacy Complaints/Issues" be included in the Dental and/or Vision Plan Document? (This is an optional
section.)
® Yes ❑ No
As a duly authorized representative of the Customer named below and its group dental and/or vision plan, and consistent with
such Customer's decision to amend its plan document to incorporate HIPAA privacy provisions, I hereby request that MetLife
include in Customer's booklet certificate HIPAA privacy language reflecting Customer's choices on this form.
Customer Name City of El Segundo
Name of Authorized Representative��
Title of Authorized Representative
Signature of Authorized Representative , Date
„� ...
APPKI' D S TO FORM.
CITY AEI T;1'EY