14-NISD 906022 Stop Loss 01-01-2024 COC.pdf

UHIAPP-TX (12/01) 1

UnitedHealthcare Insurance Company A Stock Company

185 Asylum Street Hartford, CT 06103-0450

APPLICATION FOR EXCESS LOSS INSURANCE

The undersigned Applicant requests the Excess Loss Insurance Benefits shown herein and provided by UnitedHealthcare Insurance Company, and agrees to be bound by the terms and provisions of the Excess Loss Insurance Policy.

Full Legal Name of Applicant: Northside Independent School District

5615 Grissom Road San Antonio, TX 78238

Key Contact Name: Leticia Ramirez Telephone: (210) 397-7888 Tax ID: 74-6015904

Applicant is a: School District

Nature of Business of the Group to be Insured: School District/Board Requested Effective Date: January 1, 2024

Total number of eligible persons: Employees: 9,620 Retirees: 7

Are retirees covered: Y

Agent or Broker: McGriff Insurance Services

SS No. or Tax ID: 74-6015904

Address: 8200 IH 10 West, Suite 215, San Antonio, TX 78230 210-397-7888

SPECIFIC EXCESS LOSS INSURANCE:

Benefit Period: Covered Expenses Incurred from January 1, 2024 through December 31, 2024 and Paid from January 1, 2024 through December 31, 2024.

Specific Deductible per Covered Person: $500,000

Maximum Specific Benefit per Covered Person: Unlimited

Covered Expenses Under Specific Excess Loss:

• Medical

• Stand Alone Prescription Drug Program

Specific Excess Loss Premium: $29.37 per subscriber per month

AGGREGATE EXCESS LOSS INSURANCE

Benefit Period: Covered Expenses Incurred from January 1, 2024 through December 31, 2024 and Paid from January 1, 2024 through December 31, 2024.

Covered Expenses under Aggregate Excess Loss Coverage:

• Medical

• Stand Alone Prescription Drug Program

Aggregate Percentage Reimbursable: 100%

Maximum Aggregate Benefit: $5,000,000 per Policy Year

Minimum Annual Aggregate Deductible: $90,872,507 or 95% of the first Monthly Aggregate Deductible amount times 12, whichever is greater.

UHIAPP-TX (12/01) 2

Maximum Covered Expenses per Covered Person accumulating toward the Maximum Aggregate Benefit:

$500,000

Monthly Aggregate Factors:

Choice + - $1062.66 per subscriber

Choice + HSA - $789.50 per subscriber

Choice - $858.83 per subscriber

Choice HSA - $748.49 per subscriber

Nexus ACO R - $780.04 per subscriber

Nexus ACO R HSA - $634.07 per subscriber

Aggregate Excess Loss Premium: $2.17 per subscriber per month

It is understood and agreed by the undersigned that:

a. The statements, declarations and representations made in this Application, any request for proposal, the underwriting information provided by or on behalf of the undersigned and the Plan Document are the undersigned's representations; that any Policy is issued in reliance upon the truth of such statements, declarations, and representations; and that such statements, declarations, and representations will form a part of the Excess Loss Insurance Policy. Any inaccuracy in such information or failure to disclose any such information, including all claims or possible claims, paid or pending, or which the Employer should otherwise know about, if discovered later, can result in rejection of this Application, or can change the terms, conditions or premiums, or can void coverage.

b. As a condition precedent to the approval of this Application, the undersigned shall furnish to the Company a copy of the executed Plan Document within 90 days after the date of this application describing the benefits provided by the Plan, which shall be kept on file in the office of the Company. If the Company does not receive the Plan Document within 90 days, the Company may refund all premium and the Application shall have been null and void when signed. No Excess Loss Insurance will be effective nor reimbursement made unless a Plan Document is received and accepted by the Company.

c. The Company will evaluate the undersigned's risk, as requested by this application, the underwriting data received and represented by the Plan and may require adjustments of rates, factors, and/or special limitations.

d. Any coverage resulting from this Application shall be subject to the terms and provisions of the Policy herein applied for. Coverage shall become effective on the date specified in this Application if all requirements of the Company, including the Plan Document and the underwriting requirements have been met and the required premiums paid.

e. The receipt by the Company of the first month's premium and deposit of any check drawn in connection with this Application shall not constitute an acceptance of liability. In the event the Company does not approve this application, its sole obligation shall be to refund such sum to the undersigned.

Full Legal Name of Applicant:

Signature of Authorized Person:

Print Name:

Title:

Date:

UHIAPP-TX (12/01) 3

Signature of Agent or Broker:

Printed Name of Agent or Broker:

License No.

FRAUD WARNING NOTICES: (Please review notice that applies in your state)

For applicants in Arkansas and Louisiana:

Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance, is guilty of a crime and may be subject to fines and confinement in prison.

For applicants in Colorado:

It is unlawful to knowingly provide false, incomplete or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds, shall be reported to the Colorado division of insurance within the Department of Regulatory Agencies.

For applicants in District of Columbia:

WARNING: It is a crime to provide false or misleading information to an insurer for purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the application.

For applicants in Florida:

Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree.

For applicants in Kentucky, New Mexico, Ohio, and Pennsylvania:

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.

For applicants in Maine, Tennessee and Virginia:

It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines, or a denial of insurance benefits.

For applicants in New Jersey:

Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties.

For applicants in all other states:

It is a crime to knowingly provided false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines, or a denial of insurance benefits.