35-E6 - City of Burleson (01-017859-00) 12.1.25.pdf
PDF 112 KB Posted
- Attached to
- Ancillary Insurance Benefits
- Solicitation number
- RFP 2026-018
- Issued by
- Johnson County, Texas
About this file
This document is a billing statement from Symetra Life Insurance Company for the City of Burleson, Texas, related to ancillary insurance benefits administration. The statement covers the invoice period of December 1-31, 2025, and pertains to policy number 01-017859-00 under bill group BG01-017859-00-001. The City of Burleson maintains multiple employee benefit coverages through Symetra, including basic life insurance, accidental death and dismemberment (AD&D), dependent life insurance, supplemental life insurance, spouse life and AD&D coverage, child life and AD&D coverage, short-term disability, and long-term disability insurance. As of the statement date of November 17, 2025, the plan covers 410 employees for basic life insurance with a coverage volume of $65,215,600, with additional coverage for 322 employees under short-term disability and varying enrollment numbers across supplemental and dependent plans.
The total amount due for the December 2025 billing period is payable on or before December 1, 2025, with a prior balance of $85,088.49 noted from the last payment received on August 18, 2025. Premium calculations are structured by coverage type with composite and age-banded rates, including charges of $0.094 per $1,000 for basic life insurance, $0.03 per $1,000 for basic AD&D, and $0.242 per $10 of covered benefit for short-term disability. The statement indicates that payments may be submitted via ACH/wire transfer to Wells Fargo Bank (routing number 121000248, account number 9440108315), by check payable to Symetra Life Insurance Company, or through the Group Online (GO) Portal at symetra.com/go. The document references a Premium Due Worksheet for detailed premium calculations and notes that Evidence of Insurability status can be reviewed through the online portal.
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Text version
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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 : 12/01/25 TO 12/31/25 Invoice # : A165012 Customer # : 50792 Bill Group # : BG01-017859-00-001 Policy / Policies # : 01-017859-00 Statement Run Date : 11/17/2025
NEXT PAYMENT DUE DATE: 12/01/2025
Prior Balance : $85,088.49 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 #: A165012 Invoice Period: 12/01/25 TO 12/31/25 Due Date: 12/01/2025 Statement Run Date: 11/17/2025
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
| 730: |
| 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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