33-E4 - City of Burleson (01-017859-00) 1.1.26.pdf
PDF 112 KB Posted
- Attached to
- Ancillary Insurance Benefits
- Solicitation number
- RFP 2026-018
- Issued by
- Johnson County, Texas
About this file
This is a billing statement and premium due worksheet from Symetra Life Insurance Company for the City of Burleson, Texas, documenting ancillary insurance benefits coverage for the invoice period of January 1-31, 2026. The City of Burleson maintains comprehensive life and disability insurance products through Symetra, including Basic Life, Basic Accidental Death & Dismemberment (AD&D), Basic Dependent Life, Supplemental Life, Supplemental AD&D, Supplemental Spouse Life, Supplemental Spouse AD&D, Supplemental Child Life, Supplemental Child AD&D, Short Term Disability, and Long Term Disability coverage. The statement reflects enrollment of 410 lives for basic coverage, 195 lives for supplemental life coverage, 96 lives for supplemental spouse coverage, 104 lives for supplemental child coverage, and 322 lives for short-term disability, with premium rates varying by coverage type and age bands where applicable.
The total current premium due is not fully specified in the document but is referenced on the Premium Due Worksheet to be completed by the City of Burleson. Payment terms indicate that the total amount due is payable on or before the premium due date of January 1, 2026, with a prior balance of $113,451.32 outstanding as of the statement run date of December 16, 2025. The City of Burleson may remit payment via ACH/wire transfer to Wells Fargo Bank, by check to Symetra Life Insurance Company, or through the Group Online (GO) Portal at symetra.com/go. Electronic payments are preferred, and the statement notes that the last payment received from the City was dated August 18, 2025.
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Text version
S ym etra L ife In su ran ce C o m p an y B enefits D ivision
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XTM-1049 3/18 Page 1 of 6
CITY OF BURLESON
Attn: HEATHER HUSE
141 WEST RENFRO STREET
BURLESON TX 76028
BILLING STATEMENT
Invoice Period : 01/01/26 TO 01/31/26 Invoice # : A167766 Customer # : 50792 Bill Group # : BG01-017859-00-001 Policy / Policies # : 01-017859-00 Statement Run Date : 12/16/2025
NEXT PAYMENT DUE DATE: 01/01/2026
Prior Balance : $113,451.32 Last Payments Received Date : 8/18/2025
Total Amount Due :
Bill Group Name: City of Burleson
REMINDERS:
• Please enter Total Amount Due from the Premium Due Worksheet. Premium Calculation can also be completed via the Group Online (GO) Portal (symetra.com/go).
• If Evidence of Insurability applies, please refer to the Group Online (GO) Portal for status.
• Total Amount Due is payable on or before the premium due date.
• Return the Premium Due Worksheet with your check or if paying by ACH/Wire, please email statement to: GRPEFT@SYMETRA.COM. Thank you!
Electronic Payments Preferred Please remit ACH/Wire to:
Routing/Transit Number: 121000248 Account Number: 9440108315 Bank: Wells Fargo Bank
420 Montgomery Street San Francisco, CA 94163
You may also submit payment online via our Group Online (GO) Portal (symetra.com/go).
Make Check Payable To:
Symetra Life Insurance Company P.O. Box 1491 Minneapolis, MN 55480-1491
Overnight Address:
Wells Fargo Attn: Symetra P O Box 1491 1801 Parkview Dr.
Shoreview, MN 55126
XTM-1049 3/18 Page 2 of 6
PREMIUM DUE WORKSHEET
Policy # 01-017859-00 Bill Group Name: City of Burleson Bill Group #: BG01-017859-00-001 Invoice #: A167766 Invoice Period: 01/01/26 TO 01/31/26 Due Date: 01/01/2026 Statement Run Date: 12/16/2025
Coverage Plan Age Band In Force from Last Statement Current in Force Rate per Dollar/Unit of Coverage
Current Premium Due
Basic Life 1 Composite Rate Lives: 410 Volume:65,215,600.00 Premium:$6,130.27
Lives:
Volume:
$0.094 Per $1000
Basic AD&D 1 Composite Rate Lives: 410 Volume:65,215,600.00 Premium:$1,956.47
Lives:
Volume:
$0.03 Per $1000
Basic Dependent Life 1 Composite Rate Lives: 279 Volume:0.00 Premium:$837.00
Lives:
Volume:
$3.00 Per Unit
Supplemental Life 1 Age Banded Lives: 195 Volume:24,001,000.00 Premium:$4,761.23
Lives:
Volume:
Varies Per $1000
Supplemental AD&D 1 Composite Rate Lives: 195 Volume:24,001,000.00 Premium:$720.03
Lives:
Volume:
$0.03 Per $1000
Supplemental Spouse Life 1 Age Banded Lives: 96 Volume:5,066,250.00 Premium:$1,133.26
Lives:
Volume:
Varies Per $1000
Supplemental Spouse
AD&D
1 Composite Rate Lives: 96 Volume:5,036,250.00 Premium:$151.09
Lives:
Volume:
$0.03 Per $1000
XTM-1049 3/18 Page 3 of 6
Coverage Plan Age Band In Force from Last Statement Current in Force Rate per Dollar/Unit of Coverage
Current Premium Due
Supplemental Child Life 1 Composite Rate Lives: 104 Volume:0.00 Premium:$208.00
Lives:
Volume:
$2.00 Per Unit
Supplemental Child AD&D 1 Composite Rate Lives: 104 Volume:2,080,000.00 Premium:$83.20
Lives:
Volume:
$0.04 Per $1000
Short Term Disability 1 Composite Rate Lives: 322 Volume:281,815.63 Premium:$6,819.94
Lives:
Volume:
$0.242 Per $10 (Covered Benefit)
Long Term Disability 1 Composite Rate Lives: 410 Volume:2,648,733.84 Premium:$5,562.34
Lives:
Volume:
$0.21 Per $100 (Covered Payroll)
Total Current Premium Due
Retroactive Adjustments - Please provide details of adjustment months and premium amount being taken as a credit/debit.
Coverage Plan Age Band Adjustment Period Adjustment Reason Lives/Volume Rate per Dollar/ Unit of Coverage
Premium Adjustment
Amount
Basic Life 1 Composite Rate
Lives:
Volume:
$0.094 Per $1000
Basic AD&D 1 Composite Rate
Lives:
Volume:
$0.03 Per $1000
Basic Dependent Life 1 Composite Rate
Lives:
Volume:
$3.00 Per Unit
XTM-1049 3/18 Page 4 of 6
Coverage Plan Age Band Adjustment Period Adjustment Reason Lives/Volume Rate per Dollar/ Unit of Coverage
Premium Adjustment
Amount
Supplemental Life 1 Age Banded
Lives:
Volume:
Varies Per $1000
Supplemental AD&D 1 Composite Rate
Lives:
Volume:
$0.03 Per $1000
Supplemental Spouse Life 1 Age Banded
Lives:
Volume:
Varies Per $1000
Supplemental Spouse
AD&D
1 Composite Rate
Lives:
Volume:
$0.03 Per $1000
Supplemental Child Life 1 Composite Rate
Lives:
Volume:
$2.00 Per Unit
Supplemental Child AD&D 1 Composite Rate
Lives:
Volume:
$0.04 Per $1000
Short Term Disability 1 Composite Rate
Lives:
Volume:
$0.242 Per $10 (Covered Benefit)
Long Term Disability 1 Composite Rate
Lives:
Volume:
$0.21 Per $100 (Covered Payroll)
Total Premium Adjustment Amount
XTM-1049 3/18 Page 5 of 6
Coverage Plan Age Band Adjustment Period Adjustment Reason Lives/Volume Rate per Dollar/ Unit of Coverage
Premium Adjustment
Amount
Total Current Premium Due
Total Premium Adjustment Amount
Total Amount Due
| 448: |
| PASR ST Cover Page Doc |
| 1: Cover Portrait Reversed_benefits |
| 2: Cover Portrait Reversed_benefits |
| PASR SA Doc |
| 1: PASR SA_ Pg1 |
| 2: PASR SA_ PremDue |
| 3: PASR Trans Detail Flow |
| 4: PASR Trans Detail Flow |
| 5: PASR Trans Detail Flow |
| 6: <blank page> |
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