34-E5 - City of Burleson (01-017859-00) 11.1.25.pdf

112 KB Posted

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 statement from Symetra Life Insurance Company for ancillary insurance benefits provided to the City of Burleson, Texas. The statement covers the invoice period from November 1, 2025, to November 30, 2025, and includes multiple coverage plans spanning life insurance, accidental death and dismemberment (AD&D), disability, and dependent coverage options. The City of Burleson maintains comprehensive employee benefits through this arrangement, with 410 covered lives under basic life and long-term disability plans, supplemented by voluntary plans with varying participation rates, including supplemental life (195 lives), spouse life (96 lives), and child life (104 lives) coverage options.

The statement details a prior balance of $56,725.66 with a total current premium due calculated across all coverage plans, including basic life ($6,130.27), short-term disability ($6,819.94), long-term disability ($5,562.34), supplemental life ($4,761.23), and various other coverage tiers at composite or age-banded rates. The City is invoiced monthly with payment due by November 1, 2025, and Symetra Life Insurance Company prefers electronic payments via ACH or wire transfer to Wells Fargo Bank or accepts online payments through their Group Online (GO) Portal, with an alternative mailing address provided for check payments.

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S ym etra L ife In su ran ce C o m p an y B enefits D ivision

108th A venue N

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98004-5135

S ym etra is a registered service m ark ofS ym etra Life

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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 : 11/01/25 TO 11/30/25 Invoice # : A161768 Customer # : 50792 Bill Group # : BG01-017859-00-001 Policy / Policies # : 01-017859-00 Statement Run Date : 10/20/2025

NEXT PAYMENT DUE DATE: 11/01/2025

Prior Balance : $56,725.66 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 #: A161768 Invoice Period: 11/01/25 TO 11/30/25 Due Date: 11/01/2025 Statement Run Date: 10/20/2025

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

467:
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>

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