32-E3 - 12 December 2025 Symetra A165012 Backup.pdf

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Attached to
Ancillary Insurance Benefits
Solicitation number
RFP 2026-018
Issued by
Johnson County, Texas

About this file

Written by GovTribe AI ·

This is a billing and premium statement document for the City of Burleson's ancillary insurance benefits provided by Symetra for the billing period of December 1, 2025. The document details coverage for multiple employee benefit categories including Basic AD&D, Long Term Disability (LTD), Basic Life, Supplemental Employee Life/AD&D, Supplemental Spouse Life/AD&D, Basic Spouse & Child Life/AD&D, Supplemental Child(ren) Life/AD&D, and Short Term Disability Employee Paid. The statement covers 2,229 total covered individuals across various age and coverage bands, with detailed breakdowns showing employee counts, volume, premiums, and adjustments for each benefit category and demographic segment.

The grand total premium for the billing period is $28,234.30 with no adjustments applied, based on a total volume of $162,989,142.05 in covered benefits. The document provides comprehensive line-item detail organized by age/coverage category codes, allowing the City of Burleson to verify coverage accuracy and premium calculations across all ancillary insurance products. No adjustments or credits were applied during this billing period, indicating standard rate application across all benefit categories. The statement serves as the billing record for Symetra's administration of the city's comprehensive voluntary benefits package covering life insurance, disability coverage, and related employee benefit programs.

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Billing Period: 12/01/2025

Values Row Labels Count Volume Premium Adjustments Total Premium Basic AD&D 411 $65,599,600.00 $1,967.99 $0.00 $1,967.99

33 17 $2,404,000.00 $72.12 $0.00 $72.12 40 13 $2,552,000.00 $76.56 $0.00 $76.56 32 8 $1,111,000.00 $33.33 $0.00 $33.33 50 7 $1,284,000.00 $38.52 $0.00 $38.52 36 10 $1,513,000.00 $45.39 $0.00 $45.39 31 7 $976,000.00 $29.28 $0.00 $29.28 27 18 $2,253,000.00 $67.59 $0.00 $67.59 24 13 $1,763,000.00 $52.89 $0.00 $52.89 48 8 $1,295,000.00 $38.85 $0.00 $38.85 42 10 $1,866,000.00 $55.98 $0.00 $55.98 46 7 $1,024,000.00 $30.72 $0.00 $30.72 58 2 $485,000.00 $14.55 $0.00 $14.55 51 8 $1,549,000.00 $46.47 $0.00 $46.47 35 10 $1,610,000.00 $48.30 $0.00 $48.30 47 9 $1,746,000.00 $52.38 $0.00 $52.38 55 7 $1,107,000.00 $33.21 $0.00 $33.21 54 8 $1,483,000.00 $44.49 $0.00 $44.49 49 8 $1,216,000.00 $36.48 $0.00 $36.48 26 10 $1,199,000.00 $35.97 $0.00 $35.97 37 12 $2,160,000.00 $64.80 $0.00 $64.80 41 12 $2,162,000.00 $64.86 $0.00 $64.86 64 5 $1,031,000.00 $30.93 $0.00 $30.93 44 8 $1,574,000.00 $47.22 $0.00 $47.22 52 8 $1,927,000.00 $57.81 $0.00 $57.81 23 18 $2,337,000.00 $70.11 $0.00 $70.11 43 6 $1,187,000.00 $35.61 $0.00 $35.61 30 12 $1,829,000.00 $54.87 $0.00 $54.87 57 7 $828,000.00 $24.84 $0.00 $24.84 39 14 $2,389,000.00 $71.67 $0.00 $71.67 34 16 $2,598,000.00 $77.94 $0.00 $77.94 56 2 $277,000.00 $8.31 $0.00 $8.31 60 4 $817,000.00 $24.51 $0.00 $24.51 28 6 $1,025,000.00 $30.75 $0.00 $30.75 61 4 $381,000.00 $11.43 $0.00 $11.43 38 18 $3,127,000.00 $93.81 $0.00 $93.81 25 12 $1,616,000.00 $48.48 $0.00 $48.48 53 7 $1,241,000.00 $37.23 $0.00 $37.23 62 4 $694,000.00 $20.82 $0.00 $20.82 20 6 $687,000.00 $20.61 $0.00 $20.61

Charge Summary - City of Burleson - for Symetra

Row Labels Count Volume Premium Adjustments Total Premium

59 5 $1,080,000.00 $32.40 $0.00 $32.40 45 7 $1,218,000.00 $36.54 $0.00 $36.54 66 1 $94,900.00 $2.85 $0.00 $2.85 63 2 $226,000.00 $6.78 $0.00 $6.78 29 17 $2,526,000.00 $75.78 $0.00 $75.78 22 5 $562,000.00 $16.86 $0.00 $16.86 65 2 $375,700.00 $11.27 $0.00 $11.27 21 7 $757,000.00 $22.71 $0.00 $22.71 19 3 $371,000.00 $11.13 $0.00 $11.13 71 1 $66,000.00 $1.98 $0.00 $1.98

Long Term Disability (LTD) 411 $2,658,521.54 $5,582.91 $0.00 $5,582.91 33 17 $99,926.63 $209.84 $0.00 $209.84 40 13 $101,177.97 $212.46 $0.00 $212.46 32 8 $46,163.80 $96.93 $0.00 $96.93 50 7 $51,755.01 $108.70 $0.00 $108.70 36 10 $62,880.18 $132.03 $0.00 $132.03 31 7 $40,485.24 $85.02 $0.00 $85.02 27 18 $93,499.24 $196.36 $0.00 $196.36 24 13 $73,200.39 $153.73 $0.00 $153.73 48 8 $53,702.59 $112.78 $0.00 $112.78 42 10 $73,816.08 $155.02 $0.00 $155.02 46 7 $42,225.07 $88.68 $0.00 $88.68 58 2 $17,686.71 $37.14 $0.00 $37.14 51 8 $61,597.65 $129.36 $0.00 $129.36 35 10 $66,898.20 $140.48 $0.00 $140.48 47 9 $70,033.89 $147.06 $0.00 $147.06 55 7 $43,406.01 $91.16 $0.00 $91.16 54 8 $57,057.76 $119.82 $0.00 $119.82 49 8 $49,202.36 $103.32 $0.00 $103.32 26 10 $49,771.29 $104.50 $0.00 $104.50 37 12 $87,735.50 $184.24 $0.00 $184.24 41 12 $88,982.02 $186.87 $0.00 $186.87 64 5 $36,688.18 $77.04 $0.00 $77.04 44 8 $62,320.78 $130.88 $0.00 $130.88 52 8 $72,700.33 $152.67 $0.00 $152.67 23 18 $96,949.18 $203.60 $0.00 $203.60 43 6 $44,330.99 $93.10 $0.00 $93.10 30 12 $75,944.43 $159.49 $0.00 $159.49 57 7 $34,368.53 $72.18 $0.00 $72.18 39 14 $96,821.18 $203.32 $0.00 $203.32 34 16 $104,243.84 $218.92 $0.00 $218.92 56 2 $11,483.91 $24.12 $0.00 $24.12 60 4 $31,845.39 $66.88 $0.00 $66.88 28 6 $42,610.10 $89.48 $0.00 $89.48 61 4 $15,777.15 $33.14 $0.00 $33.14

38 18 $124,959.09 $262.41 $0.00 $262.41 25 12 $67,138.89 $140.98 $0.00 $140.98 53 7 $49,068.33 $103.05 $0.00 $103.05 62 4 $28,810.97 $60.50 $0.00 $60.50 20 6 $28,540.09 $59.94 $0.00 $59.94 59 5 $40,765.99 $85.61 $0.00 $85.61 45 7 $47,405.63 $99.55 $0.00 $99.55 66 1 $6,069.90 $12.75 $0.00 $12.75 63 2 $9,362.43 $19.66 $0.00 $19.66 29 17 $103,549.78 $217.45 $0.00 $217.45 22 5 $23,254.01 $48.84 $0.00 $48.84 65 2 $20,000.00 $42.00 $0.00 $42.00 21 7 $31,423.95 $65.99 $0.00 $65.99 19 3 $15,413.20 $32.37 $0.00 $32.37 71 1 $5,471.70 $11.49 $0.00 $11.49

Basic Life 411 $65,599,600.00 $6,166.24 $0.00 $6,166.24 33 17 $2,404,000.00 $225.98 $0.00 $225.98 40 13 $2,552,000.00 $239.87 $0.00 $239.87 32 8 $1,111,000.00 $104.44 $0.00 $104.44 50 7 $1,284,000.00 $120.70 $0.00 $120.70 36 10 $1,513,000.00 $142.21 $0.00 $142.21 31 7 $976,000.00 $91.75 $0.00 $91.75 27 18 $2,253,000.00 $211.78 $0.00 $211.78 24 13 $1,763,000.00 $165.69 $0.00 $165.69 48 8 $1,295,000.00 $121.72 $0.00 $121.72 42 10 $1,866,000.00 $175.40 $0.00 $175.40 46 7 $1,024,000.00 $96.25 $0.00 $96.25 58 2 $485,000.00 $45.59 $0.00 $45.59 51 8 $1,549,000.00 $145.61 $0.00 $145.61 35 10 $1,610,000.00 $151.35 $0.00 $151.35 47 9 $1,746,000.00 $164.12 $0.00 $164.12 55 7 $1,107,000.00 $104.05 $0.00 $104.05 54 8 $1,483,000.00 $139.39 $0.00 $139.39 49 8 $1,216,000.00 $114.31 $0.00 $114.31 26 10 $1,199,000.00 $112.70 $0.00 $112.70 37 12 $2,160,000.00 $203.04 $0.00 $203.04 41 12 $2,162,000.00 $203.24 $0.00 $203.24 64 5 $1,031,000.00 $96.92 $0.00 $96.92 44 8 $1,574,000.00 $147.95 $0.00 $147.95 52 8 $1,927,000.00 $181.14 $0.00 $181.14 23 18 $2,337,000.00 $219.64 $0.00 $219.64 43 6 $1,187,000.00 $111.58 $0.00 $111.58 30 12 $1,829,000.00 $171.94 $0.00 $171.94 57 7 $828,000.00 $77.83 $0.00 $77.83 39 14 $2,389,000.00 $224.57 $0.00 $224.57

34 16 $2,598,000.00 $244.23 $0.00 $244.23 56 2 $277,000.00 $26.03 $0.00 $26.03 60 4 $817,000.00 $76.79 $0.00 $76.79 28 6 $1,025,000.00 $96.34 $0.00 $96.34 61 4 $381,000.00 $35.82 $0.00 $35.82 38 18 $3,127,000.00 $293.92 $0.00 $293.92 25 12 $1,616,000.00 $151.91 $0.00 $151.91 53 7 $1,241,000.00 $116.65 $0.00 $116.65 62 4 $694,000.00 $65.23 $0.00 $65.23 20 6 $687,000.00 $64.58 $0.00 $64.58 59 5 $1,080,000.00 $101.52 $0.00 $101.52 45 7 $1,218,000.00 $114.48 $0.00 $114.48 66 1 $94,900.00 $8.92 $0.00 $8.92 63 2 $226,000.00 $21.24 $0.00 $21.24 29 17 $2,526,000.00 $237.44 $0.00 $237.44 22 5 $562,000.00 $52.83 $0.00 $52.83 65 2 $375,700.00 $35.32 $0.00 $35.32 21 7 $757,000.00 $71.15 $0.00 $71.15 19 3 $371,000.00 $34.88 $0.00 $34.88 71 1 $66,000.00 $6.20 $0.00 $6.20

Supplemental Employee Life/AD&D 193 $23,891,000.00 $5,286.16 $0.00 $5,286.16 33 11 $1,210,000.00 $133.10 $0.00 $133.10 40 6 $880,000.00 $149.60 $0.00 $149.60 32 4 $500,000.00 $55.00 $0.00 $55.00 50 7 $950,000.00 $342.00 $0.00 $342.00 36 4 $650,000.00 $84.50 $0.00 $84.50 31 4 $530,000.00 $58.30 $0.00 $58.30 27 5 $700,000.00 $70.00 $0.00 $70.00 24 3 $350,000.00 $35.00 $0.00 $35.00 48 5 $600,000.00 $150.00 $0.00 $150.00 42 5 $770,000.00 $130.90 $0.00 $130.90 46 5 $770,000.00 $192.50 $0.00 $192.50 58 2 $240,000.00 $136.80 $0.00 $136.80 51 4 $340,000.00 $122.40 $0.00 $122.40 47 6 $840,000.00 $210.00 $0.00 $210.00 55 5 $440,000.00 $250.80 $0.00 $250.80 54 6 $730,000.00 $262.80 $0.00 $262.80 49 5 $560,000.00 $140.00 $0.00 $140.00 26 3 $550,000.00 $55.00 $0.00 $55.00 37 9 $1,090,000.00 $141.70 $0.00 $141.70 41 8 $930,000.00 $158.10 $0.00 $158.10 64 2 $190,000.00 $142.50 $0.00 $142.50 44 5 $650,000.00 $110.50 $0.00 $110.50 52 5 $450,000.00 $216.00 $0.00 $216.00 23 5 $680,000.00 $68.00 $0.00 $68.00

43 4 $430,000.00 $73.10 $0.00 $73.10 30 7 $750,000.00 $82.50 $0.00 $82.50 57 2 $40,000.00 $22.80 $0.00 $22.80 39 9 $1,290,000.00 $167.70 $0.00 $167.70 34 6 $870,000.00 $95.70 $0.00 $95.70 56 1 $150,000.00 $85.50 $0.00 $85.50 60 2 $300,000.00 $225.00 $0.00 $225.00 28 1 $150,000.00 $15.00 $0.00 $15.00 61 3 $40,000.00 $30.00 $0.00 $30.00 38 11 $1,800,000.00 $234.00 $0.00 $234.00 25 1 $100,000.00 $10.00 $0.00 $10.00 53 4 $710,000.00 $255.60 $0.00 $255.60 62 3 $260,000.00 $195.00 $0.00 $195.00 20 2 $250,000.00 $25.00 $0.00 $25.00 59 1 $100,000.00 $57.00 $0.00 $57.00 45 5 $580,000.00 $145.00 $0.00 $145.00 29 4 $370,000.00 $37.00 $0.00 $37.00 22 1 $10,000.00 $1.00 $0.00 $1.00 65 2 $91,000.00 $113.76 $0.00 $113.76

Supplemental Spouse Life/AD&D 96 $4,956,250.00 $1,229.31 $0.00 $1,229.31 33 7 $310,000.00 $34.10 $0.00 $34.10 40 3 $110,000.00 $18.70 $0.00 $18.70 32 2 $100,000.00 $11.00 $0.00 $11.00 50 5 $270,000.00 $97.20 $0.00 $97.20 36 1 $120,000.00 $15.60 $0.00 $15.60 31 1 $50,000.00 $5.50 $0.00 $5.50 27 2 $100,000.00 $10.00 $0.00 $10.00 24 1 $50,000.00 $5.00 $0.00 $5.00 48 4 $140,000.00 $35.00 $0.00 $35.00 42 2 $150,000.00 $25.50 $0.00 $25.50 46 3 $95,000.00 $23.75 $0.00 $23.75 47 5 $295,000.00 $73.75 $0.00 $73.75 55 4 $140,000.00 $79.80 $0.00 $79.80 54 4 $205,000.00 $73.80 $0.00 $73.80 49 3 $130,000.00 $32.50 $0.00 $32.50 37 4 $325,000.00 $42.25 $0.00 $42.25 41 3 $220,000.00 $37.40 $0.00 $37.40 64 2 $170,000.00 $127.50 $0.00 $127.50 44 4 $325,000.00 $55.25 $0.00 $55.25 52 4 $95,000.00 $52.20 $0.00 $52.20 43 2 $100,000.00 $17.00 $0.00 $17.00 30 3 $150,000.00 $16.50 $0.00 $16.50 39 7 $320,000.00 $41.60 $0.00 $41.60 34 3 $150,000.00 $16.50 $0.00 $16.50 60 1 $30,000.00 $22.50 $0.00 $22.50

28 1 $50,000.00 $5.00 $0.00 $5.00 61 1 $10,000.00 $7.50 $0.00 $7.50 38 5 $285,000.00 $37.05 $0.00 $37.05 53 2 $180,000.00 $64.80 $0.00 $64.80 62 2 $85,000.00 $63.75 $0.00 $63.75 59 1 $50,000.00 $28.50 $0.00 $28.50 45 3 $130,000.00 $32.50 $0.00 $32.50 65 1 $16,250.00 $20.31 $0.00 $20.31

Basic Spouse & Child Life/AD&D 276 $0.00 $828.00 $0.00 $828.00 33 13 $0.00 $39.00 $0.00 $39.00 40 12 $0.00 $36.00 $0.00 $36.00 32 7 $0.00 $21.00 $0.00 $21.00 50 7 $0.00 $21.00 $0.00 $21.00 36 8 $0.00 $24.00 $0.00 $24.00 31 6 $0.00 $18.00 $0.00 $18.00 27 10 $0.00 $30.00 $0.00 $30.00 24 3 $0.00 $9.00 $0.00 $9.00 48 7 $0.00 $21.00 $0.00 $21.00 42 8 $0.00 $24.00 $0.00 $24.00 46 5 $0.00 $15.00 $0.00 $15.00 58 1 $0.00 $3.00 $0.00 $3.00 51 7 $0.00 $21.00 $0.00 $21.00 35 9 $0.00 $27.00 $0.00 $27.00 47 8 $0.00 $24.00 $0.00 $24.00 55 6 $0.00 $18.00 $0.00 $18.00 54 8 $0.00 $24.00 $0.00 $24.00 49 5 $0.00 $15.00 $0.00 $15.00 26 2 $0.00 $6.00 $0.00 $6.00 37 9 $0.00 $27.00 $0.00 $27.00 41 12 $0.00 $36.00 $0.00 $36.00 64 4 $0.00 $12.00 $0.00 $12.00 44 6 $0.00 $18.00 $0.00 $18.00 52 6 $0.00 $18.00 $0.00 $18.00 23 4 $0.00 $12.00 $0.00 $12.00 43 5 $0.00 $15.00 $0.00 $15.00 30 10 $0.00 $30.00 $0.00 $30.00 57 3 $0.00 $9.00 $0.00 $9.00 39 13 $0.00 $39.00 $0.00 $39.00 34 12 $0.00 $36.00 $0.00 $36.00 56 1 $0.00 $3.00 $0.00 $3.00 60 2 $0.00 $6.00 $0.00 $6.00 28 3 $0.00 $9.00 $0.00 $9.00 61 3 $0.00 $9.00 $0.00 $9.00 38 17 $0.00 $51.00 $0.00 $51.00 25 2 $0.00 $6.00 $0.00 $6.00

53 5 $0.00 $15.00 $0.00 $15.00 62 3 $0.00 $9.00 $0.00 $9.00 20 1 $0.00 $3.00 $0.00 $3.00 59 4 $0.00 $12.00 $0.00 $12.00 45 6 $0.00 $18.00 $0.00 $18.00 66 1 $0.00 $3.00 $0.00 $3.00 29 9 $0.00 $27.00 $0.00 $27.00 22 1 $0.00 $3.00 $0.00 $3.00 65 1 $0.00 $3.00 $0.00 $3.00 21 1 $0.00 $3.00 $0.00 $3.00

Supplemental Child(ren) Life/AD&D: $20,000106 $0.00 $296.80 $0.00 $296.80 33 5 $0.00 $14.00 $0.00 $14.00 40 4 $0.00 $11.20 $0.00 $11.20 32 3 $0.00 $8.40 $0.00 $8.40 50 6 $0.00 $16.80 $0.00 $16.80 36 3 $0.00 $8.40 $0.00 $8.40 31 2 $0.00 $5.60 $0.00 $5.60 27 1 $0.00 $2.80 $0.00 $2.80 24 1 $0.00 $2.80 $0.00 $2.80 48 5 $0.00 $14.00 $0.00 $14.00 42 2 $0.00 $5.60 $0.00 $5.60 46 5 $0.00 $14.00 $0.00 $14.00 51 4 $0.00 $11.20 $0.00 $11.20 47 5 $0.00 $14.00 $0.00 $14.00 55 2 $0.00 $5.60 $0.00 $5.60 54 2 $0.00 $5.60 $0.00 $5.60 49 2 $0.00 $5.60 $0.00 $5.60 37 5 $0.00 $14.00 $0.00 $14.00 41 4 $0.00 $11.20 $0.00 $11.20 64 1 $0.00 $2.80 $0.00 $2.80 44 5 $0.00 $14.00 $0.00 $14.00 52 3 $0.00 $8.40 $0.00 $8.40 23 2 $0.00 $5.60 $0.00 $5.60 43 2 $0.00 $5.60 $0.00 $5.60 30 3 $0.00 $8.40 $0.00 $8.40 39 9 $0.00 $25.20 $0.00 $25.20 34 5 $0.00 $14.00 $0.00 $14.00 61 2 $0.00 $5.60 $0.00 $5.60 38 6 $0.00 $16.80 $0.00 $16.80 53 2 $0.00 $5.60 $0.00 $5.60 45 3 $0.00 $8.40 $0.00 $8.40 29 2 $0.00 $5.60 $0.00 $5.60

Short Term Disability Employee Paid 325 $284,170.51 $6,876.89 $0.00 $6,876.89 33 15 $11,765.68 $284.75 $0.00 $284.75 40 8 $8,333.92 $201.68 $0.00 $201.68

32 8 $6,391.92 $154.68 $0.00 $154.68 50 7 $7,281.48 $176.21 $0.00 $176.21 36 9 $7,988.07 $193.31 $0.00 $193.31 31 7 $5,605.65 $135.66 $0.00 $135.66 27 17 $12,257.95 $296.63 $0.00 $296.63 24 12 $9,408.52 $227.70 $0.00 $227.70 48 8 $7,435.73 $179.95 $0.00 $179.95 42 6 $6,859.59 $166.00 $0.00 $166.00 46 6 $4,461.94 $107.98 $0.00 $107.98 58 2 $2,564.31 $62.06 $0.00 $62.06 51 6 $5,875.06 $142.17 $0.00 $142.17 35 8 $7,354.02 $177.96 $0.00 $177.96 47 6 $6,534.60 $158.13 $0.00 $158.13 55 6 $5,361.96 $129.75 $0.00 $129.75 54 6 $6,008.78 $145.42 $0.00 $145.42 49 7 $6,298.30 $152.41 $0.00 $152.41 26 10 $6,891.41 $166.77 $0.00 $166.77 37 9 $8,479.75 $205.21 $0.00 $205.21 41 7 $6,776.42 $163.99 $0.00 $163.99 64 3 $2,426.05 $58.71 $0.00 $58.71 44 5 $5,277.18 $127.71 $0.00 $127.71 52 5 $6,225.09 $150.65 $0.00 $150.65 23 13 $10,006.39 $242.15 $0.00 $242.15 43 3 $3,079.11 $74.51 $0.00 $74.51 30 9 $7,673.97 $185.71 $0.00 $185.71 57 7 $4,758.72 $115.17 $0.00 $115.17 39 9 $8,476.16 $205.12 $0.00 $205.12 34 13 $10,931.38 $264.52 $0.00 $264.52 60 3 $3,024.74 $73.20 $0.00 $73.20 28 5 $4,845.82 $117.27 $0.00 $117.27 61 4 $2,184.53 $52.86 $0.00 $52.86 38 12 $11,278.38 $272.94 $0.00 $272.94 25 11 $8,400.97 $203.29 $0.00 $203.29 53 5 $5,140.22 $124.39 $0.00 $124.39 62 4 $3,989.21 $96.54 $0.00 $96.54 20 5 $3,594.27 $86.99 $0.00 $86.99 59 3 $3,681.83 $89.10 $0.00 $89.10 45 4 $4,748.30 $114.91 $0.00 $114.91 66 1 $840.45 $20.34 $0.00 $20.34 63 1 $571.60 $13.83 $0.00 $13.83 29 13 $10,376.14 $251.11 $0.00 $251.11 22 5 $3,219.79 $77.91 $0.00 $77.91 65 2 $3,000.00 $72.60 $0.00 $72.60 21 7 $4,351.01 $105.29 $0.00 $105.29 19 3 $2,134.14 $51.65 $0.00 $51.65

Grand Total 2229 $162,989,142.05 $28,234.30 $0.00 $28,234.30

File details come from the government source that posted it. Updated .