HomeMy WebLinkAbout2009/10/20 Item 5
CITY COUNCIL
AGENDA STATEMENT
~v?- CITY OF
'--!-=-CHUlA VISTA
ITEM TITLE:
SUBMITTED BY:
REVIEWED BY:
OCTOBER 20,2009, Item 2
RESOLUTION OF THE CITY COUNCIL OF THE CITY OF
CHULA VISTA APPROVING AN AGREEMENT BETWEEN
THE CITY OF CHULA VISTA AND AlVfERICAN FAMILY
LIFE ASSURANCE COMPANY OF COLUMBUS (AFLAC)
TO OFFER VOLUNTARY INSURANCE COVERAGE TO
ALL BENEFITED EMPLOYEES, AUTHORIZING PRE-TAX
PAYROLL DEDUCTIONS FOR EMPLOYEES WHO ELECT
TO PURCHASE AFLAC SUPPLEMENTAL INSURANCE
AND AUTHORIZING THE MAYOR TO EXECUTE THE
AGREEMENT. ~-/
DIRECTOR OF HUMAN RESOURCES J@~
ASSISTANT CI~AGER "'7)
CITY MANAGEr
4/STHS VOTE: YES D NO I X I
SUMMARY
To accommodate the various benefit needs of City employees without added cost to the
City, staff recommends offering AFLAC as a voluntary insurance option. Employee
premium payments will be made through employee payroll deductions. AFLAC will
administer emollment, billing reconciliation, claims processing and claims payment for the
City. Benefits will be paid directly to the employee.
ENVIRONMENTAL REVIEW
Not applicable.
RECOMMENDATION
Council adopt the resolution.
BOARDS/COMMISSION RECOMMENDATION
Not applicable.
DISCUSSION
5-1
OCTOBER 20, 2009, Item~
Page 2 of3
To accommodate the various benefit needs of City employees without added cost to the
City, staff recommends offering AFLAC as a voluntary insurance option. Employee
premium payments will be made through employee payroll deductions. AFLAC will
administer enrollment, billing reconciliation, claims processing and claims payment for the
City. Benefits will be paid directly to the employee.
Founded in 1955, American Family Life Assurance Company (AFLAC) currently has total
assets of over $76 billion. In 1958, AFLAC introduced an income protection insurance plan
for people diagnosed with cancer. Today, AFLAC policies include cancer, accident, short-
term disability, hospital confinement indemnity, life specified health event, dental, long-
term care and vision. Sample brochures describing the benefits of each insurance policy are
included in Attachment A. AFLAC has extensive experience working with the public
sector. The Deputy Sheriff's Association, City of San Diego, City of Escondido and City of
Los Angeles are some of their public sector clients.
Currently, Chula Vista Employee Association (CVEA) and Peace Officers Association
(POA) members have access to AFLAC via their unions. Staff recommends that the City
enter into an agreement with AFLAC to offer supplemental insurance to all benefited
employees, and that the City allows the premium be deducted on a pre-tax basis from
employee payroll. Initially, the following policies will be available to eligible City
employees: (1) Personal Accident Indemnity, (2) Personal Cancer Indemnity Plan, (3)
Specified Health Event Protection, (4) Hospital Confinement Indemnity, (5) Personal Long-
Term Care, and (6) Dental Basic. Premium rates will vary depending on the plan and level
of coverage an employee selects. The City will periodically evaluate the above policies and
determine if additional voluntary policies should be made available.
The scope of the work to be performed by AFLAC is outlined in the agreement between the
City of Chula Vista and AFLAC (Attachment B). The plan is to offer these options to
employees beginning January 1, 2010.
DECISION MAKER CONFLICT
Staff has reviewed the decision contemplated by this action and has determined that it is
not site specific and consequently the 500-foot rule found in California Code of
Regulations section 1 8704.2(a)(1) is not applicable to this decision.
CURRENT YEAR FISCAL IMPACT
AFLAC insurance policies are 100% employee-paid and are sold on a voluntary basis.
City will realize employment tax savings to the extent employees emoll in pre-tax
premmm programs.
ONGOING FISCAL IMPACT
AFLAC insurance policies are 100% employee-paid and are sold on a voluntary basis.
City will realize employment tax savings to the extent employees emoll in pre-tax
prenuum programs.
5-2
OCTOBER 20, 2009, Item S
Page3of3
A TT ACHMENTS
Attachments: A
B
Sample policy brochures
For Signature: Agreement between the City of Chula Vista
and AFLAC
Prepared by: Kelley Bacon, Director of Human Resources, Human Resources Department
5-3
ATTACHMENT A
Sample AFLAC
Policy Brochures
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Af~<'aC'M
Benefits are payabie for a covered person's death,
dismemberment/ or injury cQased by a covered accident that
ocears on or off rhe job.
Accident Emergency Treatment Benefit
. Atfac will pay $120 for the insured and the spouse, and $70 for
children if a covered person receives treatment for injuries
sustained in a: covered accident. This benefit is payable for
X-rays, treatment by a physician, or treatment received in a
hospital emergency room. Treatment must be received within
72 hours of the accident for benefits to J:1e payable. This
benefit is payable once per 24-hour period and only once per
covered accident, per covered person.
Accident Follow-Up Treatment Benefit
Ajfac will pay $25 for one treatment per day for up to a
maximum of six h-eatments per covered. accident, per covered
person for follow-up treatment received for injuries sustained
in a covered accident. Treatment must begin within 30 days of
the covered accident or discharge from the hospitaL
Treatments must be furnished by a physician in a physician's
office or in a hospital on an outpatient bJsis. This benefit is
not payable for the same visit that the Physical Therapy
Benefit is paid.
Initial Accident Hospitalization Benefit
Aflac wilt pay $1,000 when a covered person is confined to a
hospital for at least 24 hours for injuries sustained in a
covered accident. If the covered person is admitted directly to
an intensive care unit, Ajfac will pay $1,500. This benefit is
payable only once per hospital confinement* or intensive care
unit confinement and is payable only once per calendar year,
per covered person.
Accident Hospital Confinement Benefit
Af/ac will pay $200 per day for which a covered person is
charged for a room for hospital confinement* of at least 18
hours for treatment of injuries sustained in a covered .accident.
This benefit is payable up to 365 days per covered accident,
per covered person. The Accident Hospital Confinement
Benefit and the Rehabilitation Unit Benefit will not be paid
on the same day; only the highest eligible benefit will be paid.
Intensive Care Unit Confinement Benefit
Atlac will pay an additional $400 per day for each day a covered
person is receiving the Accident Hospital Confinement
Benefit and is confined to and charged for a room in an
intensive care unit. This benefit is payable up to 1.5 days per
covered accident, per covered person. Confinements must
start within 30 days of the accident.
Accident Specific-Sum Injuries Benefit
Aflac wi/I pay $25-$10,000 for:
Dislocations
Burns
Skin Grafts
Eye Injuries
Lacerations
Fractures
Broken Teeth
Comas
Brain Concussions
Paralysis
Surgical Procedures
Treatment must be performed on a covered person for
injuries sustained in a covered accident. We will pay for no
more than two dislocations per covered accident, per covered
person. Dislocations must be diagnosed by a physician
within 72 hours after the covered accident. Benefits are
payable for only the first dislocation of a joint. If a physician
reduces a dislocation with local or no anesthesia, we will
pay 25 percent of the amount shmvn for the closed reduction
dislocation. A physician must treat burns within 72 hours
after J covered accident. A total of 50 percent of the bum
benefit will be paid for one or more skin grafts. Lacerations
requiring sutures must be repaired under the attendance of a
physician within 72 hours after the covered accident.
Fractures must be diagnosed by a physician by X-ray within
14 days after a covered accident. For chip fractures and other
fractures not reduced by open or closed reduction, we will
pay 25 percent of the benefit amount shown for the closed
reduction. We will pay for no more than two fractures per
covered accident, per covered person. We will pay no more
than aile benefit for broken teeth per covered accident, per
covered person. Coma duration must be at least seven days
and must require intubation for respiratory assistance.
Paralysis must result from spinal cord injuries that are
received in a covered accident and that result in complete
and total loss of use of two or more limbs for a period of at
least 30 days, and the loss must be confirmed by a
physician. Surgical procedures must be performed within
one year of a covered accident. Two or more surgical
procedures performed through the same incision will be
considered one operation, and benefits will be paid based
upon the most expensive procedure. Only one miscellaneous
surgery benefit is payable per 24-hour period even though
more than one procedure may be performed.
*Hospital confinement is defined as a covered person's confinement to a bed in a hospital for which a room charge is made. The
confinement must be on the advice of a physician and medically necessary. Benefits are also payable for confinement in hospitals
operated by or for the United S.tates government. Confinement~~g start within 30 days of the accident.
Major Diagnostic Exams
At/ac will pay $150 if a covered person requires one of the
following exams for injuries sustained in J covered accident:
C1 (computerized tomography) scan, !vIRl (magnetic
resonance imaging), or EEG (electroencephalogram). The
exam must be performed in a hospital, a physician's office, or
an ambulatory surgical center, and a charge must be incurred.
This benefit is limited to one payment per calendar year, per
covered person. No lifetime maximum.
Physical Therapy Benefit
Aflac wilt pay $25 for one treatment per day up to a maximum
of ten treatments per covered accident, per covered person if a
physician advises the person to seek treatment from a physical
therapist. Physical therapy must be for injuries sustained in a
covered accident and must start within 30 days of the covered
accident or discharge from the hospital. Treatment must take
place within six months after the accident. This benefit is not
payable for the same visit that the Accident Follow-Up
Treatment Benefit is paid.
Rehabilitation Unit Benefit
Aj/ac wiff pay $100 per day when a covered person is charged
for confinement in a hospital and transferred to a bed in a
rehabilitation unit of a hospital for a covered injury. This
benefit is limited to 30 days for each covered person per
period of hospital confinement and is limited to a calendar
year maximum of 60 days. The Accident Hospital
Confinement Benefit and the Rehabilitation Unit Benefit will
not be paid on the same day; only the highest eligible benefit
will be paid. No lifetime maximum.
A period of hospital confinement is a time period of
confinement that starts while the policy is in force. If the
confinement follows a previously covered confinement, it \vill
be deemed a continuation of the first unless it is the result of
an entirely unrelated injury or the confinements are separated
by 30 days or more.
Appliances Benefit
Aflac will pay $100 if a covered person requires, as advised by
a physician, the use of a medical appliance as an aid in
personal locomotion resulting from injuries sustained in a
covered accident. This benefit is payable for crutches,
wheelchairs, leg bro.ces, back braces, and walkers, and is
payable once per covered accide~t, per covered person.
Prosthesis Benefit
Aflac wjll pay $500 if a covered person requires a prosthetic
device as a result of injuries sustained in a covered accident.
This benefit is payable once per covered accident, per covered
person and is not payable for hearing aids, wigs, or dental
aids, to include false teeth.
Blood/Plasma/Platelets Benefit
Aflac will pay $100 if a covered person requires blood, plasma,
or plntelds for the treatment of injuries sustained in a covered
accident. This benefit is not payable for immunoglobulins and
is payable only once per covered accident, per covered person.
Ambulance Benefit
Aflac will pay $150 for ground ambulance transportation or
$1,000 for air ambulance transportation if a covered person
requires ambulance transportation to a hospital or emergency
center for injuries sustJined in a covered Jccident. A licensed
professional ambulance company must provide the
transportation within 72 hours of the covered accident. If the
provider of service does not receive payment for services
provided from any other source, and provided the benefit
under the policy has not been paid, \ve will directly reimburse
such provider of service.
Transportation Benefit
Ajfac will pay $400 per round trip to a hospital if a covered
person requires special treatment and hospital confinement*
for injuries sustained in a covered accident. The hospital must
be more than 100 miles from the covered person's residence
or site of the accident. This benefit will be paid for only the
covered person for whom the treatment is prescribed, or if the
treatment is for a dependent child and commercial travel is
necessary, one of the dependent child's parents or legal
guardinns who travels with the child will also receive this
benefit. The local attending physician must prescribe the
treatment, and the treatment must not be available locally.
This benefit is payable for up to three round trips per calendar
year, per covered person. This benefit is not payable for
transportation by ambulance or air ambulance to the hospital.
Family Lodging Benefit
Aflac will pay $100 per night for one motel/hotel room for a
memba of the extended family to accompany the covered
person if treatment of injuries sustained in a covered accident
requires hospital confinement. * The hospital and motel/hotel
must be more than 100 miles from the covered person's
residence. This benefit is payable up to 30 days per covered
accid~nt and only during the time the covered person is
confined in the hospital.
American Family Life Assurance Company of Columbm (Aflac)
5-7
Accidental-Death and -Dismemberment Benefits
Aflac wiff pay the following benefit for death if it is the result
of injuries sustained in a covered accident:
Insured/Spouse Child
Common-Carrier Accidents
$100,000
$15,000
A covered person must be a passenger at the time of the
common-carrier accident, and a proper authority must have
licensed the vehicle to transport passengers for a fee.
Common-carrier vehicles are limited to airplanes, trains,
buses, trolleys, and boats that operate on a regularly scheduled
basis between predetermined points or cities. Taxis are not
included.
Insured/Spouse Child
Other Accidents
$25,000
$7,500
(Other accidents are accidents that are not classified as
commo~n-carrier accidents and that are not specifically
excluded in the limitations and exclusions.ofthe policy.)
Ai/ac will pay the following benefit for dismemberment
resulting from injuries sustained in a covered accident:
Insured/Spouse Child
Both arms and both legs $25,000 $7,500
Two eyes, feet, hands,
arms, or legs $25,000 $7,500
One eye, foot, hand,
arm, or leg $ 6,250 $1,875
One or more fingers and/or
one or more toes $ 1,250 $ 500
Death or dismemberment must be independent of disease,
bodily infirmity, or any -other cause other than a covered
accident and must occur within 90 days of the accident. Only
the highest single benefit per covered person will be paid for
accidental dismemberment. Benefits will be paid only once
for any covered accident. If death and dismemberment result
from the same accident, only the Accidental-Death Benefit
will be paid. Loss of use does not constitute dismemberment,
except for eye injuries resulting in permanent loss of vision
such that central visual acuity cannot be corrected to better
than 20/200.
Wellness Benefit
After the policy l1as been in forc.e for 12 momhs, Aflac wilt pay $60
if you or anyone family member undergoes routine
examinations or other preventive testing during the following
policy year. Eligible family members are your spouse and the
dependent children of you or your spouse. Services covered are:
allnual physical examinations, dental exams, manunograms,
Pap smears, eye examinations, inmmnizations, flexible
sigmoidoscopies, prostate-specific antigen tests (PSAs),
ultrasounds, and blood screenings. This benefit will become
available following each anniversary of the policy's effective
date for service received during the following policy year and is
payable only once per policy each 12-month period following
the policy anniversary date. Service must be under the
supervision of or reconunended by a physician and received
while your policy is in force, and a charg~ must be incurred.
Continuation of Coverage Benefit
Aflac will waive all monthly premiums due for the policy and
riders for up to two months if you meet all of the following
conditions: (1) Your policy has been in force for at least six
months; (2) we have received premiums for at least six
consecutive months; (3) your premiums have been paid
through payroll deduction and you leave your employer for
any reason; (4) you or your employer notifies us in writing
within 30 days of the date your premium payments cease
because of your leaving employment; and (5) you re-establish
premium payments, either through your new employer's
payroll deduction process or direct payment to Aflac. You will
again become eligible for this benefit aft~r you re-establish
your premium payments through payroll deduction for a
period of at least SL'{ months, and we receive premiums for at
least six consecutive months. (Payroll deduction means your
premium is remitted to Aflac for you by your employer
through a payroll deduction process.)
Guaranteed-Renewable
The policy is guaranteed-renewable for your lifetime, subject
to Aflac's right to change premiums by class upon any
renewal da te.
Effective Date
The effective date of the policy is the date shown in the Policy
Schedule, not the date the application is signed. The policy is
available through age 64. The payroll rat~ may be retained
after one month's premium payment on payroll deduction.
This brochure is for illustration purposes only.
Refer to the policy for complete details, limitations, and exclusions.
5-8
What Is Not Covered
V>le will not pay benefits for services rendered by a member
of the extended family of a covered person or for an accident
that occurs while coverage is not in force.
We will not pay benefits for an accident or sickness that is
caused by or occurs as a result ofa covered person's:
Participating in any activity or event, including the
operation of a vehicle, while under the influence of a
controlled substance (unless administered by a physician
and taken according to the physician's instructions) or while
intoxicated (intoxicated means that condition as defined by
the law of the jurisdiction in which the accident occurred);
Mountaineering using ropes and/or other equipment,
parachuting, or hang gliding;
Participating in, or attempting to participate in, an illegal
activity that is defined as a felony (felony is as d~fined by
the law of the jurisdiction in which the activity takes place);
Intentionally self-inflicting bodily injury or attempting
suicide, while sane or insane;
Having cosmetic surgery or other elective procedures that
are not medically necessary, or having dental treatment
except as a result of injmy;
Being exposed to war or any act of war, declared or
undeclared;
Actively serving in any of th~ armed forces, or units
auxiliary thereto, including the National Guard or ArnlY
Reserve;
Participating in any form of flight aviation other than as a
fare-paying passenger in a ftllly licensed, passenger-
carrying aircraft;
Participating in any sport or sporting activity for wage,
compensation, or profit, including otTiciating or coaching;
or racing any type vehicle in an organized event.
Hospital does not include any institution or part thereof used
as a rehabilitation unit; a hospice unit, including any bed
designated as a hospice or a swing bed; a convalescent home;
a rest or nursing fJcility; an extended-care facility; a skilled
nursing facility; or a facility primarily affording custodial or
educational care, care or treatment for persons suffering from
mental disease or disorders, care for the aged, or care for
persons addicted to drugs or alcohoL
Aflac shall not be liable for any loss to which a contributing
cause was the insured's commission of or Jttempt to conlinit a
felony or to which a contributing cause W8S the insured's
being engaged in an illegal occupation.
A physician does not include you or a member of your
extended family, or anyone who normally resides in your
home or residence.
Family Coverage
Family coverage includes the insured; spouse; and dependent,
unmarried children to age 19 (23 if full-time students). This
includes the relationship created by a domestic partnership.
Newborn children are automatically insured from the moment
of birth. One-parent family coverage includes the insured and
all unmarried, dependent children to age 19 (23 if full-time
students). A dependent child must be under the age of 19 at
the time of application to be eligible for coverage.
The policy to which this sales matclial peliains is written only
in English; the policy prevails if interpretation of this materia.l
vanes.
5-9
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1.800.99.AFLAC (1.800.992.3522)
En espanal:
l800.5I.AFLAC (1.800.742.3522)
Visit our Web site at aflac.com.
American Family Life Assurance Company of Columbus (Aflac) Worldwide Headqu2.r:ers 1932 Wynntoll Road Columbus, Georgia 31999 aAac.com
5-10
Personal Cancer
Indemnity Plan
A Cancer Indemnity Insurance Policy
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Form A75175BCA
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Plan Benefits
. First-Occurrence
. Hospital Confinement
. Medical Imaging
. Radiation and Chemotherapy
· Immunotherapy
. Cancer Screening Wellness
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Personal Cancer Indemnity Plan
Cancer Insurance Only; Policy Series A-75100
First-Occurrence Benefit
Af/ac will pay 51,SOO for the insured, $1,500 for the spouse, or
$2}250 for chifdren when a covered person is diagnosed with
internnl cancer. This benefit is payable only once for each
covered person and will be paid in addition to any other
benefit in this policy Internal cancer includes melanomas
classified as Clark's Level III and higher, or a Breslow level
greater than 1.5 rum. In addition to the pathological or clinical
diagnosis required by the policy, we may require additional
infom1ution from the attending physician and hospital. Any
covered person who has had a previous diagnosis of cancer
will not be eligible for a First-OccuITence Benefit under this
policy for a recurrence, extension, or metastatic spread of that
same cancer.
Hospital Confinement Benefit
Afiac will pay $200 per day when a covered person is confined
to a hospital for treatment of cancer and is charged for a room
as an inpatient. Benefits inc"rease to $400 per day beginning
with the 3] st day of continuous confinement.
A person commed to a U.S. government hospital does not need to
be charged for the Hospital Confinement Benefit to be payable.
When cancer treatment is received in a U.S. government
hospital, the remaining benefits (except the Cancer
Screening \Vellness Benefit) are not payable unless the
covered person is actually charged and is legally required to
pay for such services.
In-Hospital Drugs and Medicine Benefit
Aflac will pay $15 per day for drugs and medicine administered
to a covered person while confined in a hospital for the
treatment of cancer.
Medical Imaging Benefit
Aflac will pay $100 per calendar year when a charge is incurred
for each covered person who receives an initial diagnosis or
follow-up evaluation of internal cancer using one of the
follO\ving medical imaging exams: CT scans, MRIs, bone
scans, multiple gated acquisition (lvIUGA) scans, positron
emission tomography (PET) scans, or transrectal ultrasounds.
These exams must be performed in a hospital, an ambulatory
surgical center, or a physician's office. This benefit is payable
once per calendar year, per covered person.
Radiation and Chemotherapy Benefit
Ai/ac will pay $200 per day as follows when a charge is
incurred for a covered person who receives one or more of the
following cancer treatments for the purpose of modification
or destnlction of abnormal tissue:
1. Cytotoxic chemical substances and their administration in
the treatment of cancer:
a. Injection by medica! personnel in a physician's office,
clinic, or hospital.
b. Self-injected medications (limited to $200 per daily
treatment, subject to a monthly maximum of $1,600
for all medications).
c. Medications dispensed by a pump or implant (limited
to $200 for the initial prescription and $200 for each
pump refill, subject to a monthly maximum of $800 for
all medications).
d. Oral chemotherapy, regardless of where administered
(limited to $200 per prescription, subject to a monthly
maximum of $800 for all prescriptions).
2. Radiation therapy.
3. The insertion of interstitial or intracavitary application of
radium or radioisotopes.
If delivery of radiation or chemotherapy is other than listed
above, benefits will be subject to a monthly maximum of
$800. Treatments must be FDA- or NeI-approved for the
treatment of cancer. This benefit does not pay for laboratory
tests, diagnostic X-rays, immunoglobulins, immunotherapy,
colony-stimulating factors, therapeutic devices, simulations,
dosimetries, treatment plannings, or other procedures related
to these therapy treatments. This benefit is not payable on the
same day that the Experimental Treatment Benefit is paid.
This brochure is for illustration purposes only.
5-12
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Experimental Treatment Benefit
Af!ac will pay 5200 per day when a charge is incurred for a
covered person who receives one or more of the foUowing
experimental can~er treatments, prescribed by a physician, for
the purpose of modification or destruction of abIlOlmal tissue:
. Treatment administered by medical personnel in a
physician's office, clinic, or hospital.
. Self-injected medications (limited to $200 per daily
treatment, subject to a monthly maximum of $1,600).
. Medications dispensed by a pump (limited to $200 for the
initial prescription and $200 for each refill, subject to a
monthly maximum of $800).
. Oral medications, regardless of where administered (limited
to $200 per prescription} subject to a monthly maximum of
S800 for all prescriptions).
Treatments must be approved by the National Cancer Institute
(NCI) as viable experimental treatments for cancer. This
benefit does not pay for laboratory tests, diagnostic X-rays,
immunoglobulins, immunotherapy, colony-stimulating factors,
therapeutic devices, or other procedures related to these
therapy treatments. This benefit is not payable on the same
day that the Radiation and Chemotherapy Benefit is paid.
Immunotherapy Benefit
Af/ac will pay $300 per calendar month during which a charge is
incurred for a covered person who receives immunoglobulins
or colony-stimulating factors as prescribed by a physician as
part of a treatment regimen for internal cancer. Any
medications paid under the Radiation and Chemotherapy
Benefit or the Experimental Treatment Benefit will not be
paid under the Immunotherapy Benefit. Lifetime maximum of
$] ,500 per covered person.
Antinausea Benefit
Af/ac witl pay $100 per calendar mO/1th during which a charge
is incurred for a covered person who receives antinallsea
drugs that are prescribed while receiving radiation or
chemotherapy treatments.
Attending Physician Benefit
Aflac wiff pay $15 per day when a charge is incurred for a
covered person who is confined in a hospital and who
requires the services of a licensed physician, other than the
surgeon who performed the surgery. The tenn visit shall mean
an actual personal call by the physician. This benefit is
payable for only the number of days the Hospital
Confinement Benefit is payable.
Nursing Services Benefit
Aflac wi/! pa.y $100 per 24.ho~lr day if, while confined in a
hospital, a covered person requires and is charged for ptivate
nursing services other than those regularly furnished by the
hospital. Services must be required and authorized by the
anending physician. This benefit is not payable for private
nurses who are members of your immediate family. This
benefit is payable for only the number of days the Hospital
Confinement Benefit is payable.
Skin Cancer Surgery Benefit
Aflac wi/I pay the indemnity ($100 to $600) listed when a
surgical operation is performed on a covered person for a
diagnosed skin cancer and a charge is incurred for the
specific procedure. The benefit listed in the policy includes
anesthesia services.
Surgical/Anesthesia Benefit
Aflac will pay the indemnity ($95 to $3,000) listed in the
Schedule of Operations when a surgical operation is
performed on a covered person for a diagnosed internal
cancer and a charge is incurred. If any operation for the
treatment of cancer is perfom1ed other than those listed, Aflac
will pay an amount comparable to the amount shown for the
operation most similar in severity and gravity. (Exceptions:
Surgery for skin cancer will be payable under the Skin Cancer
Surgery Benefit. Reconstructive surgery will be paid under
the Reconstructive Surgery Benefit.) Two or more surgical
procedures performed through the same if!cision will be
considered one operation, and the highest eligible benefit will
be paid.
Aflac will pay an indemnity benefit equal to 25% of the amount
shown in the Schedule of Operations for the administration of
anesthesia during a covered surgical operation. The combined
benefits payable in the Surgical/Anesthesia Benefit for any
one operation will not exceed 53,750.
Outpatient Hospital Surgical Benefit
AJ1ac will pay $200 when a surgical operation is performed on a
covered person for a diagnosed internal cancer and an operating
room charge is incurred. Surgeries must be performed on an
outpatient basis in a hospital, to include an ambulatory surgical
center. This benefit is not payable for surgery perfonned in a
physician's office or for skin cancer surgery. This benefit is
pnyable in addition to the Surgica.lI Anesthesia Benefit, is
payable once per day, and is not payable on the same day as the
Hospital Confinement Benefit.
Refer to the policy for complete details, limitations, and exclusions.
5-13
Prosthesis Benefit
Aflac will pay $2;500 when a charge is incurred for surgically
implanted prosthetic devices that are prescribed as a direct
result of surgery for cancer treatment. Lifetime maximum of
$5,000 per covered person.
Aflac will pay $200 when a charge is incurred for
nonsurgically implanted prosthetic devices that are prescribed
as a direct result of cancer treatment. Lifetime maximum of
$400 per covered person.
The Prosthesis Benefit does not include coverage for a breast
transverse rectus abdominus myocutaneous (TRAM) flap
procedure listed under the Reconstructive Surgery Benefit.
Reconstructive Surgery Benefit
Aflac will pay the indemnity ($325 to $2,500) listed when a
surgical operation is performed on a covered person for
reconstructive surgery for the treatment of cancer and a
charge is incurred for the specific procedure. Aflac will pay an
indemnity benefit equal to 25% of the amount shown in the
policy for the administration of anesthesia during a covered
reconstmctive surgical operation. If any reconstmctive
surgery is perfonued other than those listed, Aflac will pay an
amount comparable to the amount shown in the policy for the
operation most similar in severity and gravity.
In~Hospital Blood and Plasma Benefit
Ajfac will pay S50 times the number of days paid under the Hospital
Confinement Benefit if a covered person receives blood and/or
plasma during a covered hospital confinement and a charge is
incUlTed. This benefit does not pay for immunoglobulins,
immunotherapy, or colony-stimulating factors.
Outpatient Blood and Plasma Benefit
Affac will pay S200 for each day a covered person receives
blood and/or plasma transfusions for the treatment of cancer
as an outpatient in a physician's office, clinic, hospital, or
ambulatory surgical center, and a charge is incurred. This
benefit does not pay for inununoglobulins, immunotherapy, or
colony-stimulating factors.
Second Surgical Opinion Benefit
,Af/a, wiff pay $200 when a charge is incurred for a second
surgical opinion concerning cancer surgery for a diagnosed
cancer by a licensed physician. This benefit is not payable the
same day the NCI Evaluation/Consultation Benefit is payable.
National Cancer Institute (NCI)
Evaluation/Consultation Benefit
Af/ac wiff pay $500 when a covered person seeks evaluation or
consultation at an NeI-designated cancer center as a result of
receiving a prior diagnosis of internal cancer. The purpose of
the evaluation/consultation must be to detem1ine the
appropriate course of cancer treatment. If the NeI-designated
cancer center is more than 50 miles from the covered person's
residence, Aflac wiff pay $250 for the transportation and lodging
of the covered person receiving the evaluation/consultation.
This benefit is also payable at the Aflac Cancer Center &
Blood Disorders Service of Children's Healthcare of Atlanta.
This benefit is not payable the same day the Second Surgical
Opinion Benefit is payable. This benefit is payable only once
under this policy per covered person.
Ambulance Benefit
Aflac will pay $200 for ground ambulance transportation or
$1;000 for air ambulance transportation when a charge is
incurred for ambulance transportation of a covered person to
or from a hospital where the covered person is confined
overnight for cancer treatment. The ambulance service must
be performed by a licensed professional ambulance company.
This benefit is limited to two trips per confinement. If the
provider of service does not receive payment for services
provided from any other source, we will directly reimburse
such provider of service.
Transportation Benefit
Afiac wiff pay 40 cents per mite for round-trip transportation
between the hospital or medical facility and the residence of
the covered person when a covered person requires cancer
treatment that has been prescribed by the local attending
physician. Benefits are limited to $1,200 per round trip. This
benefit will be paid only for the covered person for whom the
treatment is prescribed. If the t.reatment is for a dependent
child and commercial travel (coach-class plane, train, or bus
fare) is necessJry, Aflac wil1 pay this benefit for up to two
adults to accompany the dependent child. This benefit is not
payable for transportation to any hospital/facility located
within a 50-mile radius of the residence of the covered person
or for transportation by ambulance to or from any hospital.
Lodging Benefit
AJfac wi/f pay $50 per day when a charge is incurred for
lodging for you or anyone adult family member when a
covered person receives cancer treatment at a hospital or
medical facility more than 50 miles from the covered person's
residence. This benefit is not payable for lodging occurring
more than 24 hours prior to treatment or for lodging occurring
more than 24 hours following treatment. This benefit is
limited to 90 days per calendar year.
5-14
Bone Marrow Transplantation Benefit
At/ac wiff pay $10,000 when a covered person incurs a charge
for a bone marrow transplantation for the treatment of cancer.
This does not include the harvesting of peripheral blood cells
or stem cells and subsequent reinfusion. Af/ac will pay the
covered person's bone marrow donor a benefit of $1,000 for his
or her expenses incurred as a result of the transplantation
procedure. Lifetime maximum of $10,000 per covered person.
Stem Cell Transplantation Benefit
Aflac will pay $2,500 when a charge is incurred if a covered
person receives a peripheral stem cell transplantation for the
treatment of cancer. This benefit does not include the
harvesting, storage, and subsequent rein fusion of bane
!1l;)rrow from the recipient or a matched donor under general
anesthesia. This benefit is payable once per covered person.
Lifetime maximum of S2,500 per covered person.
Extended-Care Facility Benefit
Af/ac will pay $100 per day when a charge is incurred if a
covered person receives Hospital Confinement Benefits and,
within 30 days of hospital confinement, is confined to an
extended-care facility, a skilled nursing facility, a
rehabilitation unit or facility, a transitional C3re unit, or any
bed designated as a s\ving bed, or to a section of the hospital
used as such. This benefit is limited to the same number of
days that the covered person received Hospital Confinement
Benefits. For each day this benefit is payable, Hospital
Confinement Benefits are not payable. If more than 30 days
separates a st::q in an extended~care facility, benefits are not
payable for the second confinement unless the covered
person was again confined to a hospital prior to the second
such confinement. Lifetime maximum of 365 days per
covered person.
Hospice Benefit
Affac will pay a one. time benefit of $500 for the first day and
S50 per day thereafter for hospice care when a covered person
is diagnosed with cancer, therapeutic intervention directed
toward the cure of the disease is medically detelmin~d no
longer appropriate, and the covered person's prognosis is one
in which there is a life expectancy of six months or less as the
direct result of cancer. This benefit is not payable the same
day the Home Health Care Benefit is payable. Lifetime
maximum of $12,000 per covered person.
5-15
Home Health Care Benefit
Aflac will pay $50 per day when a charge is incurred for home
health care or health supportive services when provided on a
covered person's behalf within seven days of release from the
hospital for the treatment of cancer. The attending physician
must prescribe such services to be performed in the home of
the covered person and certify that, if th~se services were not
available, the covered person would have to be hospitalized to
receive the necessary care, treatment, and services. These
services must be performed by a person who is licensed,
certified, or othe[\~,'ise duly qualified to perform such services
on the same basis as if the services had been performed in a
health care facility. This benefit is not payable the same d<1Y
the Hospice Benefit is payable. This benefit is limited to ten
visits per hospitalization and 30 visits in any calendar year for
each covered person.
Cancer Screening Wellness Benefit
This is a preventive benefit; a diagnosis of cancer is not
required for this benefit to be payable.
Pflac wifl pay $40 per calendar year when a charge is incurred
for one of the following: breast ultrasound, biopsy, flexible
sigmoidoscopy,.bemocult stool specimen, chest X-ray, CEA
(blood test for colon cancer), CA 125 (blood test for ovarian
cancer), PSA (blood test for prostate cancer), thennography,
colonoscopy, or virtu::II colonoscopy. These tests must be
performed to detelmine whether c~mcer exists in a covered
person. This benefit is limited to one payment per calend::Ir
year. per covered person.
Mammography and Pap Smear Benefit
This is ::I preventive benefit; a di::Ignosis of cancer is not
required for this benefit to be p3yable.
AfFac wifl pay $100 per calendar year when a charge is
incurred for an annual screening by low-dose mammography
for the presence of occult breast cancer, and Af/ac wilt pay $30
per calendar year when a charge is incurred for a ThinPrep or
an annual Pap smear. These tests must be performed to
determine whether cancer exists in a covered person. This
benefit is limited to one payment per calendar ye;)r, per
covered person.
The Following Benefits Have No Lifetime Maximum:
Hospital Confinement, In-Hospital Drugs and Medicine,
Medical Imaging, R3diation and Chemotherapy, Experimental
Treatment, Antinausea. Attending Physician, Nursing
Services, SurgicaVAnesthesia, Outpatient Hospital Surgical,
Skin Cancer Surgery, Reconstructive Surgery, In-Hospital
Blood and Plasma, Outpatient Blood and Plasma, Second
Surgical Opinion. Ambulance, Transportation, Lodging,
Home Health Care, Cancer Screening Wellness, and
Mammography and Pap Smear.
Waiver of Premium Benefit
If you, due to having internal cancer, are completely unable to
do all of the usual and customary duties of your occupation [or,
if you are not employed: are completely unable to perform two
or more of the activities of daily living (ADLs) without the
assistance of another person] for a period of 90 continuous
days, Aflac will waive, from month to month, any premiums
falling due during your continued inability. For premiums to be
waived, Aflac will require an employer's statement (if
appli~able) and a physician's statement of your inability to'
perform said duties or activities, and may each month thereafter
require a physician's statement that total inability continues.
Aflac may ask for and use an independent consultant to
determine whether you can perform an ADL without assistance.
Atlac will also waive, from month to month, any premiums
falling due while you are receiving hospice benefits under the
Hospice Benefit.
Continuation of Coverage Benefit
Aflac will waive all monthly premiums due for the policy and
riders for two months if you meet all of the following
conditions: (1) Your policy has been in force for at least six
months; (2) we have received premiums for at least six
consecutive months; (3) your premiums have been paid
through payroll deduction; (4) you or you~ employer has
notified us in writing within '30 days of the date your
premium payments ceased due to your leaving employment;
and (5) you re-establish premium payments through your new
employer's payroll deduction process or direct payment to
Aflac. YOU will again become eligible to receive this benefit
after you re-establish your premium payments through payroll
deduction for a period of at least six months, and we receive
premiums for at least six consecutive months. (Payroll
deduction means your premium is remitted to Aflac for you
by your employer through a payroll deduction process.)
Guaranteed-Renewable
This policy is guaranteed-renewable for your lifetime, subject
to Aflac's right to change premiums by class upon any
renewal date.
Effective Date
The effective date of this policy is the date shown in the Policy
Schedule, not the date the application is signed. This policy is
available through age 64 on payroll deduction and through age
64 on direct billing. The payroll rate may be retained after one
month's premium payment on payroll deduction.
Family Coverage
Family coverage includes the insured; spouse; and dependent,
unmarried children to age 25. Newborn children are
automatically insured from the moment of birth. One-parent
family coverage includes the insured and all dependent,
unmarried children to age 25
5-16
Limitations and Exclusions
Aflac pays only for treatment of cancer, including direct
extension, metastatic spread, or recurrence, and other diseases
and conditions caused, complicated, or aggravated by or
resulting from cancer or cancer treatment. Benefits are not
provided for premalignant conditions; conditions with
malignant potential; or any other disease, sickness, or
incapacity. Pathological proof of diagnosis must be submitted.
Clinical diagnosis will be accepted when such diagnosis is
consistent with professional medical standards, provided
medical evidence sustains the diagnosis of cancer. 'When
clinical diagnosis is acceptable, the date of diagnosis will be
the date on the clinical diagnosis report stating that there is a
positive diagnosis of cancer.
This policy contains a 30-day waiting period. If a covered
person has cancer dingnosed before coverage has been in
force 30 dnys from the effective date of coverage shown in
the Policy Schedule, benefits for treatment of that cancer will
apply only to treatment occurring after two years from the
effective date of the policy. Or, at your option, you may elect
to void the policy from its beginning and receive a full refund
of premium.
The First-Occurrence Benefit is not payable for: (1) any
internal cancer diagnosed or treated before the effective date
of this policy and the subsequent recurrence, extension, or
metastatic spread of such internal cancer that is diagnosed
prior to the effective date of this policy; (2) cancer diagnosed
during this policy's 30-day waiting period; (3) the diagnosis
of skin cancer or melanomas classified as Clark's Levels I and
II, or a Breslow level less than or equal to 1.5 mm. Any
covered person who has had a previous diagnosis of cancer
will not be eligible for a First-Occurrence Benefit under this
policy for a recurrence, extension, or metastatic spread of that
same cancer.
Benefits for the Radiation and Chemotherapy Benefit and the
Experimental Treatment Benefit will not be paid for each day
the radium or radioisotope remains in the body or for each
day of continuous infusion of medications dispensed by a
pump or implant. (The Surgical! Anesthesia Benefit provides
additional amounts payable for insertion and removaL)
Hospital does not include any institution, or part thereof, used
as a hospice unit, including any bed designated as a hospice
bed; a swing bed; a convalescent home; a rest or nursing
facility; a psychiatric unit; a rehabilitation unit or facility; an
extended-care facility; a skilled nursing facility; or a facility
primarily affording custodial or educational care, care or
treatment for persons suffering from mental diseases or
disorders. care for the aged, or care for persons addicted to
drugs or alcohoL
The policy to which this sales material pertains is written
only in English; the policy prevails if interpretation of this
material varies.
Understanding the Risk*
According to the American Cancer Society:
. In the United States, men have a little less than a 1-in-2 lifetime risk of developing cancer; for
women the risk is a little more than 1-;n-3.
. About 1,368,030 new cancer cases are expected to be diagnosed in 2004.
. Since 1990, over 18 million new cancer cases have been diagnosed.
As advances in cancer treatment continue, more and more people will survive:
. Approximately 9.6 million Americans with a history of cancer were alive in January 2000.
. The five-year relative survival rate for all cancers combined is 630/0.
The National Institutes of Health estimated the overall costs for cancer in the
year 2003 at $189.5 billion.
Although health insurance can help offset the costs of cancer treatment, you stlll may have to cover
deductibles and copayments on your own.
Additionally, cancer treatment can cause out-of-pocket expenses that aren't covered by traditional
health insurance:
. Travel
. Food
. Lodging
. Long-distance calls
. Child care
. Household help
M'eanwhile, living expenses such as car payments, mortgages or rent, and utility bills continue,
whether or not you are able to work. If a family member has to stop working to take care of you,
the loss of income may be doubled. AfJac helps provide an important safety net in fighting the
financial consequences of cancer that result beyond traditional health insurance.
Aflac's Persona! Cancer Ii'demnity Plan pays benefits directly to you, unless assigned.
You use the cash however XQ.!!. decide.
Afi;aCTM
"American Cancer Socit:ty. Cancer Facts & FlgUrcS 2004
5-17
Aflac is ...
. A Fortune 500 company with assets exceeding $59 billion}
insuring more than 40 million people worldwide.
. Rated AA in insurer financial strength by Standard & Poor's
(April 2004), Aa2 (Excellent) in insurer financial strength by
Moody's Investors Service (March 2003), A+ (Superior) by
AM. Best (June 2004), and AA in insurer financial strength
by Fitch, Ine. (December 2003).*
. Named by Fortune magazine to its list of America's Most
Admired Companies for the fifth consecutive year in March 2005.
. A premier provider of insurance policies with premiums payroll
deducted for more than 300,000 payroll accounts nationally.
", :":~-'~1.t;!;~
. Outstanding in claims service! with most claims processed
within four days.
t;_:
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. Included by Forbes magazine in its annual Platinum 400 List
of America's Best Big Companies since 2000 (January 2004),
. Named by Fortune magazine to its list of the 100 Best
Companies to Work For in America for the seventh
consecutive year in January 2005.
Ratings refer only to the overall financial status of Aflac alld are not
recommendations of specific policy provisions, fCltes) or practices.
.\~" .
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1.800.99.AFLAC (1.800.992.3522)
En espana I:
1.800.5I.AFLAC (1.800.742.3522)
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Visit our Web site at aflac.com.
Your local .;ffac insut"ance ag~I-.t/pi-oducer
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American Family Life Assurance Company of Columbus (Aflac) Worldwide Headquartei"s 1932 Wynnton ROZld Columbus, Georgia 31999 aflac.com
5-18
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Plan 1
Specified Health
Event Protection
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Specified Health Event Insurance
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Primary specified health events covered by the Specified Health
Event Protection policy include:
. Coma
. Stroke
. Paralysis
. Heart Attack
End-Stage Renal Failure
Major Third-Degree Burns
Persistent Vegetative State
Coronary Artery Bypass Surgery
. Major Human Organ Transplant
$5,000 First.Occurrence Benefit
Aflac wiff pay $5,000 for the named insured and spouse or
$7,500 for each dependent child covered under the policy
when he or she is first diagnosed as having had a primary
specified health event. This benefit is paid only once for each
covered person and will be paid in addition to any other
benefit in the policy. Lifetime maximum is $5,000 per named
insured and spouse, and $7,500 per dependent child.
$2,500 Reoccurrence Benefit
Aflac will pay $2,500 for each covered person under the policy
if he or she has been paid under the First-Occurrence Benefit
and is later diagnosed as having had a primary specified
health event that occurs more than 180 days after the First-
Occurrence Benefit last became payable. This benefit will
a.gain become payable for a. primary specified health event
when it occurs more than 1 SO days after the Reoccurrence
Benefit last became payable. No lifetime ma.ximum.
Hospital Confinement Benefit*
Af/ac wi!1 pay $300 for each day a covered person incurs a
charge for hospital confinement for the treatment of a covered
primary specified health event. Confinement for treatment of
the covered primary specified health event must occur within
500 days following the occurrence of the most recent covered
primary specified health event. This benefit is payable for
only one cuvereu primary specified health event at a time per
covered person. Treatment or confinement in a U.S.
government hospital does not require a charge for benefits to
be payable.
Continuing Care Benefit*
Aflac wi/{ pay $125 each day a covered person is charged for
receiving any of the follo\\wg treatments from a licensed
physician as a result of a covered primary specified health t:vent:
Dialysis
. Hospice Care
. Extended Care
. Physician Visits
. Speech Therapy
. Physical Therapy
. Home Health Care
. Nursing Home Care
Respiratory Therapy
. Occupational Therapy
. Rehabilitation Therapy
Dietary Therapy jConsultation
Treatment is limited to 60 days for continuing care received
within 180 days following the occurrence of the most recent
covered primary specified health event. Daily maximum for this
benefit is $125 regardless of the number of treaOnents received.
*If the Hospital Confinement Benefit and the Continuing
Care Benefit are payable on the same day, only the highest
eligible benefit will be paid. No lifetime maximum.
Ambulance Benefit
Aflac will pay $250 if, due to a covered primary specified
health event, a covered person requires ground ambulance
transportation to or from a hospital. Aflac wilt pay $2,000 if,
due to a covered primary specified health event, a covered
person requires air ambulance transportation to or from a
hospitaL A licensed professional or licensed volunteer
ambulance company must provide the ambulance service. If
the provider of service does not receive payment for services
provided from any other source, and provided the benefit
under the policy has not been paid, we will directly reimburse
such provider of service. This benefit will not be paid for
more than two times per occurrence of a primary specified
health event. Ambulance benefits are nor payable beyond the
1 80th day following the occurrence of a covered primary
specified health event. No lifetime maximum.
American Family Life Assurance Company of Columbus (Aflac)
5-20
Transportation Benefit
Aflac wi!1 pay 50 cents per mile for noncommercial travel or
the costs incurred for commercial travel (coach class plane,
train, or bus farc) for transportation of a covered person for
the round-trip distance between the hospital or medical
facility and the residence of the covered person if a covered
person requires special medical treatment that has been
prescribed by the local attending physician for a covered
primary specified health event. This benefit is not payable for
transportation by ambulance or air ambulance to the hospital.
Reimbursement will be made for only the method of
transportation actually taken. This benefit will be paid' only
for the covered person for whom the special treatment is
prescribed. If the special treatment is for a dependent child
and commercial travells necessary, Aflac will pay this benefit
for up to two adults to accompany the dependent child. The
benefit amount payable is limited to $1,500 per occurrence of
a covered primary specified health event. Transportation
benefits are not payable beyond the 180th dav fallowino the
occurrence of a covered primary specified h:alth event~ This
benefit is not payable for transportation to any hospital
located within a 50.mile radius of the residence of the covered
person. No lifetime maximum.
Lodging Benefit
Aflac will pay the charges incurred up to 575 per day for lodging
far you or anyone adult family member when a covered
person receives special medical treatment for a covered
primary specified health event at a hospital or medical
facility. The hospital, medical facility, and lodging must be
more than 50 miles from the covered person's residence. This
benefit is not payable for lodging occurring more than 24
hours prior to treatment or for lodging occurring more than 24
hours following treatment. This benefit is limited to 15 days
per occurrence of a covered primary specified health event.
Lodging benefits are not payable bevond the 180th dav
following the occurrence of a cover~d primary specifi~d
health event. No lifetime maximum.
The Continuing Care Benefit, Ambulance Benefit.
Transportation Benefit, and Lodging Benefit will be paid for
care received within 1 SO days following the occurrence of a
covered primary specified health event. Benefits are paya.ble
for only one covered primary specified health event at a time
per covered person. If a covered person is eligible to receive
benefits for marc than one covered primary specified health
event, we will pay benefits only for care received within the
1 SO days following the occurrence of the most recent event.
Secondary Specified Health Event Benefit
A;.!fac wi!! pay $250 for each covered person under the policy
who has coronary angioplasty, with or without stents. This
benefit is limited to one coronary angioplasty per 30-day
period. No lifetime maximum.
Mammography Benefit
Aflac wifl pay $150 per policy year when a charge is incurred
for an annual screening by lO\v-dosc mammography for the
presence of occult breast cancer. This benefit is limited to one
payment per policy year, per covered person. No lifetime
maximum.
Waiver of Premium Benefit
If you, due to a primary specified health event, are completely
unable to do all of the usual and customary duties of your
occupation [if you arc not employed: are completely unable to
perform three or more of the activities of daily living (ADLs)
.without the assistance of another person1 for a period of 90
continuous days, Aflac will waive, from month to month, any
premiums falling due during your continued inability For
premiums to be waived, Aflac will require an employer's
statement (ifapplicablc) and a physician's statement of your
inability to perform said duties, and mav each month
thereafter require a physician's state11le~t that total inability
continues.
Continuation of Coverage Benefit
Aflac will waive all monthly premiums due for the policy and
riders for two months if you meet all of the following
conditions: \ 1) your policy has been in force for at least six
months: (2) we have received premiums for at least six
consecutive months; (3) your premiums have been paid
through payroll deduction; (4) you or your employer has
notifIed us in writing within 30 days of the date your
premium payments ceased due to your leaving employment;
and (5) you re-est:tblish your premium payments through your
new employer's payroll deduction process or direct payment to
Atlac:. You will again become eligible to receive this benefit
after you re-establish your premium payments through payroll
deduction for a period qf at least six months and we receive
premiums for at least six consecutive months. Payroll
deduction means your premium is remitted to Aflac for you
by your employer through a payroll deduction process.
Guaranteed-Renewable
The policy is guaranteed-renewable for your lifetime, subject
to Aflae '5 right to change premiums by class upon any
renewal date.
5-21
Definitions
The following specified health events must occur after the
effective date of coverage for benefits to be payable:
PrimQ/Y Specified Health Event: heart attack, stroke, coronary
artery bypass surgery, end-stage renal failure, major human
organ transplant, major third-degree bums, persistent
vegetative state, coma, or paralysis.
Coma: a continuous state of profound unconsciousness,
dia\mosed or treated after the effective date of the policy,
lasting for a period of seven or more consecutive days and
characterized by the absence of (I) spontaneous eye movement,
(2) response to painful stimuli, and (3) vocalization. The
condition must require intubation for respiratory assistance.
Coronary Artery Bypass Surgery: open-heart surgery to correct
narrowing or blockage of one or more coronary arteries with
bypass grafts but excluding procedures such as, but not
limited to, coronary angioplasty, laser relief, or other
nonsurgical procedures. This does not include valve
replacement surgery.
End-Stage Renal Failure: permanent and irreversible kidney
failure, not of an acute nature, requiring dialysis or a kidney
transplant to maintain life.
Heart Attach: a myocardial infarction, coronary thrombosis, or
coronarY occlusion that is diagnosed or treated after the
eff'ectiv; date of the policy. The attack must be positively
diagnosed by a physician and must be evidenced by
electrocardiographic findings or clinical findings together
with blood enzyme findings. The definition of heart attack
shall not be construed to mean congestive heart failure,
atherosclerotic heart disease, angina, coronary artery disease,
or any other dysfunction of the cardiovascular system.
Major Human Organ Transplant: a surgery in which a covered
person receives, as a result of a surgical transplant, one or
more of the following human organs: kidney, liver, heart,
lung, or pancreas. .It does not include transplants involving
mechanical or nonhuman organs.
Major Third-Degree Burns: an area of tissue damage in which
there is destruction of the entire epidermis and underlying
dennis and that covers more than 10 percent of total body
surface. The damage must be caused by heat, electricity,
radiation, or chemicals.
Paralysis: spinal cord injuries resulting in complete and total
loss of use of two or more limbs (paraplegia, quadriplegia, or
hemiplegia) for a continuous period of at least 30 days. The
paralysis must be confirmed by your attending physician.
Persistent Vegetative State: a state of severe mental
impairment in which only involuntary bodily functions are
present and for which there exists no rcasonabk expectation
of regaining significant cognitive function. The procedure for
establishing a persistent vegetative state is as follows: two
physicians, one of whom must be the attending physician, who,
after persoll311y examining the covered person, shall certify- in
writing, based upon conditions found during the course of their
examination, that (1) the covered person's cognitive function
has been substantially impaired, and (2) there exists no
reasonable expectation that the covered person will regain
significant cognitive function.
Secondary Specified Health Evenc coronary angioplasty with or
without stents occurring after the effective date of coverage.
Stroke: apoplexy due to rupture or acute occlusion of a
cerebral artery that is diagnosed or treated after the effective
date of the policy. The apoplexy must cause complete or
partial loss of function involving the motion or sensation of a
part of the body and must last more than 24 hours. The stroke
must be positively diagnosed by a physician based upon
documented neurological deficits and confirmatory
neuroimaging studies. Stroke does not mean head injury,
transient ischemic attack (TIA), or cerebrovascular
insufficiency.
Family Coverage
Family coverage includes the insured; spouse (including the
relationship created by a domestic partnership); and
dependent, unmarried children to age 25. Newborn children
are automatically insured as any other family member. One-
parent family coverage includes the insured and dependent,
unmarried children to age 25.
Effective Date
The effective date is the date shown in the Policy Schedule,
not the date you signed the application for coverage. The
payroll rate may be retained after one month's premium
payment on payroll deduction.
5-22
Pre-Existing Conditions
A pre-existing condition is an illness, disease, disorder, or
injury for which, within the sL'{-month period before the
effective date of coverage, medical advice, consult3tion, or
treannent was recommended by or received from a physician.
Benefits for a primary or secondary specified health event
that is caused by a pre-existing condition will not be covered
unless the primary or secondary specified health event occurs
more than 30 days after the effective date. Any reoccurrence
of a primary or secondary specified health event occurring
more th:m 30 days after the effective date will be covered.
Limitations and Exclusions
Benefits are not payable for losses or confinements that occur
or begin before the policy effective date or after tennination
of the policy.
Benefits for a primary or secondary specified health event
that is caused by a pre-existing condition will not be covered
unless the primary or secondary specified health event occurs
more than 30 days after the effective date. Benefits are
payable for only one covered primary or secondary specified
health event at a time per covered person.
The policy does not cover losses or confinements caused by
or resulting from: (I) any loss sustained or contracted due,
directly or indirectly, to a covered person's being intoxicated
or under the influence of any controtled substance unless
administered on the advice of a physician; (2) participating in
any sport or sporting activity for wage, compensation, or
profit; (3) intentionally self-inflicting bodily injury or
attempting suicide; or (4) being exposed to war or any act of
war, declared or undeclared, or actively serving in any of the
armed forces or units auxiliary thereto, including the National
Guard or Reserve.
The term hospital does not include any institution or part
thereof used as an emergency room; a rehabilitation unit; a
hospice unit, including any bed dt:signated as a hospice bed or
a swing bed; a transitional care unit; a convalescent homc; a
rest or nursing facility; a psychiatric unit; an extended-care
facility; a skilled nursing facility; or a facility primarily
affording custodial or educational care, care or treatment for
persons suffering from mental disease or disorders, care for
the aged, or care for persons addicted to drugs or alcohol.
A physician does not include you or a member of your
extended family, or anyone \\'ho normally resides in your
home or residence.
The policy to which this sales material pertains is written only
in English; the policy prevails if interpretation of this material
vanes.
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5-23
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American Family Life Assul'ance Company of Columbus (Aflac) . Worldwide Headquaners 1932 WYllntOr. Road. Columbus, Georgia 31999 aflac.com
Plan 1
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Hospital
Protection
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Hospital Confinement Indemnity Insurance ...
... what you need, when you need it.
Aff"BC'M
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Annual Hospitalization Confinement Benefit
Aflac will pay the amount listed below for the first five days
of hospitalization when a covered person requires hospital
confinement* for a covered sickness or injury and a charge is
incurred.
SiCRrieSS
$400 per day
$500 pcr day
fnjw)'
Benefits for the Annual Hospitalization Confinement Benefit
are limited to a total benefit payment of five days per calendar
year, per policy. Confinements not separated by 30 days or
more, or hospitalization that begins prior to the end of one
calendar year and continues into the next calendar year will be
considered one confinement.
Daily Hospital Confinement Benefit
Aflac wiIJ pay S 100 per day for the period of hospital
confinement* when a covered person requires hospital
confinement for a covered sickness or injury. This benefit is
payable in addition to the Annual Hospitalization
Confinement Benefit. The maximum benefit period for any
one period of hospital confinement is 365 days. No lifetime
maximum.
*Hospital confinement does not include emergency rooms.
Treatment or confinement in a U.S. government hospital does
not require a charge for benefits to be payable.
Rehabilitation Unit Benefit
AjItJ.c wj// pay $'/00 per day for each day you are charged when
a covered person is confined in a hospital and is transferred to
a bed in a rehabilitation unit of a hospital for a covered
sickness or injury. This benefit is limited to 15 days for each
covered person per period of hospital confinement and is
limited to a calendar year maximum of 30 days per covered
person. No lifetime ma,"'{imum.
Mammography Benefit
Aflac wiil pa-y 5150 per calendar year for each covered person
when a charge is incurred for a marmnogram. This is a
preventive benefit; hospitalization of a covered person is not
required for this benefit to be pnyable. No lifetime maximum.
Waiver of Premium Benefit
Aflac will waive from month to month, for the named insured
only, any premium(s) falling due during the named ins\lred's
continued hospital confinement. This benefit will begin after
the named insured has received Daily Hospital Confinement
Benefits from the policy for 30 consecutive days. When Daily
Hospital Confinement Benefits are no longer being paid,
premium payments must be resumed. Once premium
payments are resumed, any new confinements must again
satisfy the 30-day continued confinement for premiums to be
waived. If you die and your spouse becomes the new named
insured, premiums will start again at the appropriate rate and
will be due on the first premium due date after the change.
The new named insured will then be eligible for this benefit if
the need arises.
Guaranteed-Renewable
The policy is guaranteed-renewable for your lifetime,
subject to Aflac's right to change premiums by class upon
any renewal date.
Family Coverage
Family coverage includes the insured; spouse; and dependent,
unmarried children to age 19 (or 23 if they are full-time
students). This includes the relationship created by a domestic
partnership. Newborn children are automatically insured from
the moment of birth. One-parent family coverage includes the
insured and dependent, unmarried children to age 19 (or 23 if
they are full-time students). A dependent child must be under
age 19 at the time of application to be eligible for coverage.
Effective Date
The effective date is the date shown in the Policy Schedule,
not the date the application is signed. Payroll rates may be
retained after one month's premium payment on payroll
deduction.
American Family Life Assurance Company of Columbus (Aflac)
5-26
Pre. Existing Conditions
A pre-existing condition is an illness, disease, or disorder for
which, within the 12-month period before the effective date of
coverage, medical advice, consultation, or treatment was
reconunended or received, or for which symptoms existed that
would ordinarily cause a prudent person to seek diagnosis,
care, or treatment. Care or treatment caused by a pre-existing
comlition will not be covered unless it begins more than six
months after the effective date of coverage. A sickness is an
illness, disease, or disorder, independent of injury, diagnosed
or treated after the effective date of coverage and while
coverage is in force.
Limitations and Exclusions
Any illness, disease, or disorder diagnosed by a physician or
medically treated during the 12 months prior to the effective
date of the policy wi!( not be covered, unless the loss begins
more than six months after the effective date of the policy.
The policy does not cover losses caused by or resulting from
intentionally self-inflicting bodily injury or attempting
suicide; participating in or attempting to participate in any
illegal activity that is classified as a felony (the term felony is
as defined by the law of the jurisdiction in which the activity
takes place); being exposed to war or any act of war, declared
or undeclared, or actively serving in any of the armed forces
or units auxiliary thereto, including the National Guard or
Reserve; having treatment for a mental or nervous disorder or
disease; alcoholism or drug dependency; any loss sustained or
contracted due to a covered person's being intoxicated or
under the influence of any controlled substance upless
administered on the advice of a physician; having cosmetic
surgery that is not medically necessary; having elective
surgery that is not medically necessary within the first 12
months of the effective date uf the policy; pregnancy or
childbirth within the first ten months of the effective date of
the policy (complications of pregnancy will be covered to the
same extent as a sickness); routine nursing or well-baby care
for a newborn child; being hospitalized before the effective
dnte of coverage; or donating an organ within the first 12
months of the effective date of the policy.
If the period of hospital confinement follows a previously
covered confinement, it will be deemed a continuation unless
the Inter confinement is the result of an entirely unrelated
sickness or injury, or the confinements are separated by 30
days or more during which the covered person is not confined
in any institution or facility.
Hospital does not include any institution or part thereof used
as an emergency room; a rehabilit:1tion unit; a hospice unit,
including any bed designated as a hospice or a swing bed; a
convalescent home; a rest or nursing facility; a psychiatric
unit; an extended-care facility; a skilled nursing facility; or a
facility primarily affording custodial or educational care, care
or treatment for persons suffering from mental disease or
disorders, care for the age(~ or care for persons addicted to
drugs or alcohol. BenefIts for confinement in a rehabilitation
unit are payable under the Rehabilitation Unit Benefit.
Complications of pregnancy do not include premature
delivery without incidence, false labor, occasional spotting,
prescribed rest during pregnancy, morning sickness, and
similar conditions associated with the management of a
difficult pregnancy not constituting a classifiably distinct
complication of pregnancy. Cesarean deliveries are not
considered complications of pregnancy.
The policy to which this sales material pertains is written only
in English; the policy prevails if interpretation of this material
varies.
This is a brief summary of coverage. Refer to the policy for complete details, limitations, and exclusions.
5-27
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1.800.99.AFLAC (1.800.992.3522)
En espanal:
1.800.5LAFLAC (1.800.742.3522)
Visit our Web site at aflac.com.
AmPI ican Family Life Assurance Company of Columbus (Aflac) Worldwide Headquarters 1932 Wynnton Road Columbus, Georgia 31999 aflac.com
5-28
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Personal Long-Term
Care Plan
Comprehensive Long-Term Care Insurance
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When first diagnosed as chronically ill, you often have many
needs: specialized equipment for the homef occasional visits from
a home health aide, or special training for a family member to
provide assistance. You may even want the services of a care
coordinator. But, the costs for these items can add up-fast!
That's why Ailac's long.tenn care policy automatically provides
you a First-Occurrence Benefit!
First-Occurrence Benefit
Ai/ac will pay the First-Occurrence Benefit you select for each
covered person when first diagnosed as chronically ill. This
benefit is intended to assist the covered person with the
expenses associated with qualified long-term care services.
This benefit is payable only once per lifetime for each
covered person and will be paid in addition to any other
benefit in the policy.
Nursing Home Daily Benefit
Aflac wiff pay the Nursing Home Daily Benefit you select for
each day a covered person is confined and requires qualified
long-term care services in a nursing home. This benefit is
subject to the nursing home benefit period. Alzheimer's
facilities that are licensed as such by the state and that meet
the policy requirements will be covered.
Aifac will pay the Nursing Home Daily Benefit amount you
select to reserve a bed in a nursing home facility if a covered
person temporarily leaves the nursing home facility while
receiving qualified 10ng-tem1 care services. This benefit is
limited to a 21-day calendar year maximum per person.
Waiver of Premium Benefit
Ailac will waive, from month to month, any premium falling
due during the nmned insured's continued nursing home
confinement, after you have received Nursing I-lame Daily
Benefits for 60 consecutive days. When Nursing Home Daily
Benefits are no longer being paid, premium payments must be
resumed. Once premium payments are resumed any new
confinements must again satisfy the 60-day continued
confinement requirement for premiums to be waived.
Residential Care Daily Benefit
Ajlac will pay the charges incurred up to the Residential Care
Daily Benefit you select for each day a covered person is
confined and requires qualified long-term care services in a
residential care facility. This benefit is subject to the
residential care benefit period. This benefit includes facilities
licensed as hospice facilities and respite care. Facilities not
necessarily named as residential care facilities may be covered
if they meet the policy requirements.
The Nursing Home Daily Benefit, Residential Care Daily
Benefit, and Home Care Benefit will not be paid on the same
day. Only the highest eligible benefit will be paid.
Home Care Benefit
Aflac wif/ pay the charges incurred up to the Home Care Daily
Benefit amount you select for each visit during which a
covered person receives qualified long-tem1 care services for:
. Home Health Care
. Homemaker Services
. Personal Care
. Respite Care
. Hospice Services
. Adult Day Care
. Adult Foster Care
Multiple services received on the same day will be counted as
one visit; this benefit is limited to one visit per day.
Qualified long-tem1 care services are the necessary
diagnostic, preventive, therapeutic, curative, treatment,
mitigation and rehabilitative services, and maintenance or
personal care services that are required by a chronically ill
,individual. These services must be provided according to a
plan of care prescIibed by a licensed health care practitioner
(a physician, registered professional nurse, licensed social
worker, or other licensed individual) independent of the
insurer. The tenn licensed health care practitioner does not
include you, a member of your immediate family, or anyone
who normally resides in your home or residence.
American Family Life Assurance Company of Columbus (Aflac)
5-30
~g::~;~!fr1:E::ilt'i~
Flexibility... Choice ... Value
First, YOU choose the length of coverage that's right for you.
Plan 1
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Plan 2
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Plan 3
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Plan 4
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Nursing Home Daily Benefit
2 Years 3 Years
5 Years Lifetime
Residential Care Daily Benefit
1 Year 2 Years
2 Years 2 Years
Home Care Benefit
250 Visits
400 Visits
500 Visits
500 Visits
Each benefit period stands [done. A claim under one benefit will not reduce the limits of the other benefits!
Then, YOU choose the amount of coverage that's right for you.
I
I gption 1 I gption 2 ! gption 3 I gption 4 I
r- ----------- -C' ..-- .---."- -', --------- '.-.---:- ----- ___.I
:~;::occurrence._1 S3,0001 ' S3,6~~, ' .S4,500. , f .s~,go.o_ 1
Nursing Home I I
Ca~~pays:__,___lS~9g/Day .. ,j,S:J?9/i:)ay .~:J,s,9ID~y _,L~"9g/i:lay .J
" I"
I"~ I I i
I I' I'
....) S80/DaY._'1~96!Day._S1~~ID~y. "__I S1~0([)~y____ '
I II
S60/Day S7S/Day S100/Day
, I
Benefits
Residential Care
, p~t.~,-.~~:P.~?:~.
Home Care
pays up to:
SSO/Day
.
...~-:-.~.,
~.~.",...,.~~~{~.T ~~,~.~~t,!.~t~\~?i~[~~~~~Th,~~t;1~l~.J;:.~H~~,1~0~t.~~1I.~~~~.'~
!:7; " :nle~':\J la:rl'-"V1' 'S'blsl{benefitS~dire'ctl 'jB:'''' oIT"'unles'5~as~i-ne'dt~F'~'" """'-,'
i- .~~?t~'^ l'~/'PJ:.Y,,!,,;,~~~;...,. :;:~;:-i:~.,:~.,:;.;;..",;,.r:;,;,~, 'Yl-: ::;;,!.L""::":It!:;'"i'~::'t".;~."lti. ',,' ,:0S';;;
~~~:. :p,>,::\re"~'rdress:of.any- iother~in'surance yoti-have"'JThere is'no waitihrg'
".J.~,_...~~,.....1..,.. "~,,...."""~,i'-""'t<. ~ ,J.....;.~'._.,~ ~...."-_ ~..... ",~",'h_,~._ ,Jf",,~ '~.:;""''''''_.''''-~~V''''''~'. .
~~I~r f;'" """':errrrnnationo;""'erioat':Onc~"'(ju ;~'G-alifyt)'olf,'''':etta.'fa:fmnieCiiate! '
""~:',,.:+ ,","','" ,-,",>"".,."";;,,.,.:P~..-,~.,,,,,,,,. \;,"" ""I'Y""'" 8.,., "'''''' ,.Yc"" ..,g"" .,;,P. ....~"1<' ;'_.;"',,~' ..,~,..".~~"Y
t~;:'",- Y6'cr~b'w-rlYtnetp~-61 i~?;Mak'e'";'one~~;:rrem~iUhf'pl.'a'y"'m~nranci' k~re""'~6'
.. ' ,"""""'~ .,..,....,., '..h..... r,"''''''--;, ,'. ,-",,,"",,,,,, ''''nr~'''''''' .' '.'".,""..........'.,....... .,
.,cove"ra-. ~e';as;lona~as "'oti~nke;at~thesa.me: ~'a""'i61 ~}-afel ,,!{?~'.~
"M':<E:tj~Mjl~~ITrti!f~~~~~Jt:~;~~jfD'D~1I~~f~g~~i~~}}.;!~~~}.~m~l:~:::~;;:~:.~
This brochure is for illustration purposes only.
Refer to the policy and riders for complete details, limitations, and exclusions.
5-31
How to Qualify for Benefits
To qualify for benefits under the policy, you must be certified
as chronically ill, which means that you are currently (within
the preceding 12-month period) certified by a licensed liealth
care practitioner (independent of the insurer) as:
1. Being unable to perform two or more activities of daily
living (ADLs) without substantial assistance for at least 90
days due to a loss of functional capacity or
2. Suffering from an impaimlent of cognitive ability that
requires substantial supervision for your protection from
threats to health and safety.
Activities of Daily Living (ADLs)
The activities of daily living are bathing, continence, dressing,
eating, toileting, and transferring. Please refer to the policy
for complete definitions.
Effective Date
The effective date of the policy is the date shovm in the Policy
Schedule. The effective date is not the date you signed the
application for coverage.
Pre-Existing Conditions
Subject to the truthful completion of your application, the
policy fully covers all health conditions that you may
presently have, subject to the terms of the policy, as of the
policy effective date shown in the Policy Schedule.
Renewal Provision
The policy is guaranteed-renewable for your lifetime. Aflac
may change the premium rate, but only if the rate is changed
for all policies of this class.
Contingent Benefit Upon Lapse
If your policy lapses, you may be eligible for a Contingent
Benefit that provides for your coverage to continue on a
limited basis. Please refer to your policy or outline of
coverage for further details.
The policy to which this sales material pertains is written
only in English; the policy prevails if interpretation of this
material vmies.
Limitations and Exclusions
The policy will not pay benefits for that portion of any expense
that is for services which are reimbursable under Medicare (or
would be so reimbursable but for the application of the
Medicare deductible or coinsurance amounts).
The policy does not cover any of the following:
services rendered by a member of your immediate family;
services for which a charge would not be made in the
absence of this insurance;
care rendered by a Veterans Administration or federal
government facility, unless you or your estate is charged for
such care;
being exposed to war or any act of war, declared or
undeclared, or service in any of the armed forces;
intentionally self-inflicted bodily injury or attempted
suicide (while sane or insane);
the treatment of alcoholism or drug addiction.
The policy will not pay benefits for care rendered outside the
United States or its possessions.
The benefits payable by the policy will not qualify for Medi-Cal
Asset Protection under the Califomia Partnership for Long-
Term Care.
A nursing home facility is not a hospital; a residential care
facility; a personal care home; a hospice facility; a home for
the aged; a rest home; or a place primarily for domiciliary,
residential, or retirement living, or a similar establishment.
A physician does not include you, a member of your
immediate family, or anyone who normally resides in your
home or residence.
A home cannot be a hospital, a nursing home facility, a
residential care facility, or any other such type facility.
5-32
Buying Long-Term Care Insurance Today May Save You Money Tomorrow!
Long-term care coverage helps provide critical financial support if
a chronic condition incapacitates you or your spouse for an
extended time. Aj/aefs plan offers a choice of benefit packages
that include nursing homeJ residential care, and home health care
assistance as weff as afirst-occurrcnce cash payment.
The Cost and Need for Coverage Continue to Surge.
. Nationally, the average annual cost for a private room
(single occupant) in a nursing home is $70,912
(S194.28Jday). The average annual cost for a semiprivate
room (double occupancy) is 562,532 (5171.32/day).'
. Nationally, the average monthly cost for a private one-
bedroom unit in an assisted-living facility is $2,691.20
(532,294.40/year). The average hourly rate for a certified
home care provider is $36.22.1
. Doctors and hospitals are under tremendous pressure to get
patients out as quickly as possible. Patients often go to a
nursing home to continue the recovery period.
A Disability Knows No Age Limit!
An estimated ten million Americans need assistance from
others to carry out everyday activities.2 More important, long-
term care isn't just for the elderly and the retired; injuries can
incapacitate the young as well as the aged-sometimes with
longer-lasting implications.
Who Uses Long-Term Care?l
The
Elderly
Working-Age Adults
and Children
Why Buy Early?
. The need exists at any age.
. Capitalize on your current good health.
. Take advantage of lower age-based issue rates.
Buy at Your Current Age-and Save!
The cost difference between buying a long-term care policy
at age 50 compared to buying the same policy at age 65 is
substantial.
_._ ~l[f~~~~~1t~JI~rf~
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~rIl~ii~~~i~fi:,".:_H"
A ff..I:ll"'5\
. tOiu
TM
, Genworth Financial 2006 Cost of Care Survey, March 1006
'Long-Term Care: Understanding Medicaid's Role for the Elderly and Disabled, Kaiser Commission on Medicaid and the Uninsured. :-<ovember 1005
5-33
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Aflac is ...
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"~~s~ri_0g~:~~~ than:~O-ri)i1./.i.?;n ~.~.h..~!~~cifl~~{~~,'.::..:'!' .>'; _
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(June 2006); Aa2 (Excell~tit) in in~u~erJiti-a~.ci~1 stre~g-ih by'
.. . Mood/sliwestors Servic:~ (Jan~~iy ~001),~::- (S~p-,"i~rl by,
A.,tyt.:~est (Jyne 2006); and J:.,0. in. insu~er fr.n,~.nc~al ~t:e~gth- ,<. "-
nyFitch; Inc. (June 2006).~{j . .'" " ""l:
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::A~D:1iied Compani~s..fqr Jhe: 5ev~!i'th'~oQ~esu~ive ye'4f:in;~ "; ',,', /' .. ~
'. ,~ ,. . ,. , 0 . , :-',:O.-f
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.0 'N~!l1~d by ~?~u.~~'~~g~iri~ .~c:'its F~~~of1~.~~!.60'~.~4::~/':..,_" ,:~~ '\' ,i;':
. COf.l:lpa0i~.'t9 WqXkF~T.in ~me'~.~a:f<?;',th.e'n.iht~ ~g~s~cgti\(~...) :~';::y.;
ye.~~:in')anu~r:r.?OO( '.; :..,c'." ::L:" ,:~'~-:,:::.i' :-; ~:;: ",'i~.~.:~1~',;';~:;:{;:
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.. _ _ r.ecPI1~mendQt~~,ns uf spe~ific p'ol~.CJ p'~vjsfons~ ratcs, or P'fQl.cic,;:<'~:
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1.800.99.AFLAC (1.800.992.3522)
En espanol:
1.800.5I.AFLAC (1.800.742.3522)
Visit our Web site at aflac.com.
.,
>
Al11eric:an Family Life ,'\ssumnce Company of Columbus (Atlac) Worldwide Headqualters 1932 WYI1nton Road Columbus, Gemgia 31999 aflac.com
5-34
Aflac Dental Insurance - Basic Coverage
Policy Series A81100
Dental Wellness Benefit
Aflac will pay $25 per visit to you or any covered person for anyone treatment listed below. This benefit is payable once per
visit, regardless of the number of treatments received. For benefits to be payable, dental wellness visits must be separated by 150
days or more. This benefit is payable twice per policy year, per covered person. The treatment must be performed by a dentist or
dental hygienist. There is no waiting period for this benefit.
00110
00120
00150
00160
00170
00180
00425
0/110
Oll20
0120]
Ol203
01204
01205
01310
Ol320
01330
04910
09430
09910
Initial Oral Evaluation
Peliodic Oral Evaluation
Comprehensive Oral Evaluation (new or established patient)
Detailed and Extensive Oral Evaluation (problem-focused by report)
Re-cvaluation - Limited, Problem (established patiei.1t; not postoperative visit)
Comprehensive Periodontal Evaluation (new or established patient)
Caries Susceptibility Tests
Prophylaxis (adult)
Prophylaxis (child)
Topical Application of Fluoride (child, including prophylaxis)
Topical Application of Fluoride (child, prophylaxis not included)
Topical Application of Fluoride (adult prophylaxis not included)
Topical Application of Fluoride (adult, including prophylaxis)
Nutritional Counseling for Control of Dental Disease
Tobacco Counseling for the Control and Prevention of Oral Disease
Oral Hygiene Instructions
Periodontal Maintenance
Office Visit for Observation (during regularly scheduled hours, no other services performed)
Application of Desensitizing Medicament
X.Ray Benefit
AJfac wiff pay $10 per visit to you or any covered person for anyone of the X-ray procedures listed below. This benefit is payable
once per visit, regardless of the number of X-rays received, This benefit is payable only once per policy year, per covered
person, The treatment must be performed by a dentist or dental hygienist. There is no waiting period for this benefit.
D0210 Intraoral (complete series, including bitewings)
D0220 Intraoral (periapical, first film)
D0230 Intraoral (periapical, each additional film)
00240 [ntraoral (occlusal film)
00250 Extraoral (first film)
00260 Extraaral (each additional film)
D0270 Bitewing (single film)
D0272 Bitewings (two films)
D0274 Bitcwings (four films)
D0277 Vertical Bitewings (seven to eight films)
D0330 Panoramic Film
00340 Cephalometric Film
Refer to the policy for complete details, limitations, and exclusions.
American Family Life A~~urance Company of Columbus (Aflac) , Worldwide Headquai'ters 1932 Wynnton Road Columbus. Georgia 3,999 a-Aac.com
Form A81175BCA IC(6/05)
5-35
Scheduled Benefits
The benefits listed below are subject to waiting periods as shown and a policy year maximum of $1,200 per covered person.
Benefits will be paid only for specific ADA codes as listed in the policy when a charge is incurred for the covered dental
treatment while coverage is in force.
Other Preventive Benefits
Benefits in this category are subject to a 6-mooth waiting peliod.
01351 Sealant (per tooth) .....
01510 Space Maintainer (fixed, unilateral)....
01515 Space Maintainer (fixed, hilateral).
D1520 Space Maintainer (removable, unilateral)
Dl525 Space Maintainer (removable, bilateral)
D1550 Recementation of Space Maintainer
$ 15
80
100
80
100
35
Other Diagnostic Benefits
Benefits in this category are subject to a 3-mooth waiting period. Benefits 00130 and 00140 are payable
only for visits where no other covered services are performed.
DOl30 Emergency Oral Evaluation... ........... ...
00140 Limited Oral Evaluation. . ........
D0290 Posterior-Anterior or Lateral Skull and Facial Bone Survey Film
00310 Sialography.. ..........
D0415 Bacteriologic Studies for Determination of Pathologic Agents.
00460 Pulp Vitality Tests. . . . . . . . . . . . . . . . . . . . .
D0470 Diagnostic Casts.
D0471 Diagnostic Photographs.
00501 Histopathologic Exam
$ 20
20
60
160
10
, 15
20
10
40
Fillings and Other Basic Restorative Benefits
Benefits in this category are subject to a 3-month waiting period.
02140 Amalgam (one surface)
Primary..... .
Permanent. .
02150 Amalgam (two surfaces)
Primary...... .
Permanent. . .
02160 Amalgam (three surfaces)
Primary ..... . . . . . . .
Permanent. .
D2161 Amalgam (four or more surfaces)
Primary. . . .
Permanent. . . . . . . . . . .
Resin-Based Composite (one surface, anterior)
Resin-Based Composite (two surfaces, anterior)
Resin-Based Composite (three surfaces, anterior). . . . . . . . . .
Resin-Based Composite (four or more surfaces or involving incisal angle, anterior)
Resin-Based Composite Crown (anterior).
Resin-Based Composite (one sUlface, posterior)
Primary.
Permanent. . . . . . . . . .
D2392 Resin-Based Composite (two surfaces, posterior)
Prin1ary ... . . . . . . . . . . . . . . . . . . . .
Permanent. . . . . . . . . . . . . . . . . . . . . .
D2393 Resin-Based Composite (three surfaces, posterior)
Plirnary. ...........
Permanent. . . .
$ 30
45
30
50
40
55
02330
02331
02332
D2335
02390
02391
45
60
40
50
55
60
60
30
40
45
50
50
55
5-36
02394
02410
02420
Resin-Based Composite (four or more surfaces, posterior)
Primary. ........
Permanent. . . . . . .
Gold Foil (one surface)
Gold Foil (two surfaces).
50
55
200
225
Crowns and Other Major Restorative Benefits
Benefits in this category are subject to a 12-month waiting period.
02510
02520
02530
02542
02543
02544
02610
02620
02630
02642
02643
02644
02650
02651
02652
02662
02663
02664
02710
02720
02721
02722
02740
02750
02751
02752
02780
02781
02782
02783
02790
02791
02792
02910
02920
02930
0293]
02932
02933
02940
02950
02951
02952
02954
02955
02970
02980
Inlay (metallic, one surface) ...........
Inlay (metallic, two surfaces). .
Inlay (metallic, three or more surfaces).
Oulay (metallic, two surfaces).
Onlay (metallic, three surfaces).
Golay (metallic, four or more surfaces)
Inlay (porcelain/ceramic, one surface).
Inlay (porcelain/ceramic, two surfaces).
Inlay (porcelain/ceramic, three or more surfaces).
Onlay (porcelain/ceramic, two surfaces) . . . . . . . . .
Oulay (porcelain/ceramic, three surfaces) .
Onlay (porcelain/ceramic, four or more surfaces).
Inlay (resin-based composite, one surface) . . . . .
Inlay (resin-based composite, two surfaces) .. . . . . . . . . .
Inlay (resin-based composite, three or more surfaces)
Onby (resin-based composite, two surfaces) .
Onlay (resin-based composite, three surfaces)
Onlay (resin-based composite, four or more surfaces)
Crown (resin, indirect).
Crown (resin with high noble metal) . . . . . . . . . . .
Crown (resin with predominantly base metal).
Crown (resin with noble metal) . . . . . . . . . . . . . .
Crown (porcelain/ceramic substrate) .
Crown (porcelain fused to high noble metal)
Crown (porcelain fused to predominantly base metal) .
Crown (porcelain fused to noble metal).
Crown (3/4-east high noble metal) . .
Crown (3/4-cast predominantly base metal) . .
Crown (3/4-east noble metal)
Crown (3/4-porcetain/eeramic) . . .
Crown (full-cast high noble metal) . . . . . . . . .
Crown (full-cast predominantly base metal)
Crown (full-cast noble metal)
Recement Inby. . . . . . . . . . .
Recement Crown
Prefabricated Stainless Steel Crown (primary tooth) ...................
Prefabricated Stainless Steel Crown (permanent tooth) . .
Prefabricated Resin Crown . . . . . . . .
Prefabricated Stainless Steel Crown \'lith Resin \Vindow.
Sedative Filling
Core Buildup (including any pins).
Pin Retention (per tooth, in addition to restoration) . . .
Cast Post and Core (in addition to crown)
Prefabricated Post and Core (in addition to crown).
Post Removal (not in conjunction with endodontic therapy).
Temporary Crown (fractured tooth). . . . . . . . . . .
Crown Repairs, by Report . . . . . . . . .
$190
225
350
225
250
275
200
225
350
250
275
325
ISO
200
250
225
250
250
150
250
250
250
250
250
250
250
250
250
250
250
250
250
250
30
30
65
75
100
110
25
65
15
95
lOa
75
75
125
5-37
Root Canals and Other Endodontic Benefits
Benefits in this category are subject to a 12-month waiting period.
03110 Pulp Cap (direct, excluding final restoration).
D3120 Pulp Cap (indirect, excluding final restoration) . .
D3220 Therapeutic Pulpotomy (excluding final restoration) Removal of Pulp Coronal to the
Dentinocemental Junction and Application of Medicament ..
Pulpal Therapy (resorbable filling; anterior, primary tooth, excluding final restoration).
Pulpal Therapy (resorbable filling; posterior, primary tooth, excluding final restoration)
Anterior (excluding final restoration, root canal) . . . . .
Bicuspid (excluding final restoration, root canal).
Molar (excluding final restoration, root canal) . . . . . . .
Root Canal (four or more)
Retreatment of Previous Root Canal Therapy (anterior). . . . . . .
Retreatment of Previous Root Canal Therapy (bicuspid) . . . . .
Retreatment of Previous Root Canal Therapy (molar)
Apexification/Recalcification (initial visit; apical closure/calcific repair of perforations,
root resorption, etc.). . . . . . . . . . . . . . . . . . . . . . . . . . . .
03352 ApexificationlReca1cificntion (interim medication replacement; apical closurelcalcific
repair of perforations, root resorption, etc.).
03353 Apexification/Recalcification (final visit; includes completed root canal thernpy; apical
closure/calcific repair of perforations, root resorption, etc.)..
Apicoectomy/Periradicular Surgel)' (anterior).. .........
Apicoectomy/Periradicuiar Surgery (bicuspid; first root) . .
Apicoectomy/Periradicular Surgery (molar; first root) . . . .
Apicoectomy/Periradicular Surgery (each additional root).
Retrograde Filling (per root) . .
Root Amputation (per root) . . . . . . . . . . . . . . . . . . .
Hemisection (including any root removal; not including root canal therapy)
Canal Preparation and Fitting of Preformed Dowel or Post. . . . .
03230
03240
03310
03320
03330
D3340
03346
03347
03348
03351
D3410
03421
03425
03426
03430
03450
03920
03950
Gum Treatments/Periodontic Benefits
Benefits in this category are subject to a 6-month waiting period.
D4210 Gingivectomy or Gingivoplasty (four or more contiguous teeth or bounded teeth spaces
per quadrant) .. . . . . . . . . . . . .
D4211 Gingivectomy or Gingivoplasty (one to three teeth per quadrant) ..
D4240 Gingival Flap Procedure, Including Root Planing (four or more contiguous teeth or
bounded teeth spaces per quadrant) . . . . . . . . . . . .
Gingival Flap Procedure, Including Root Planing (one to three teeth per quadrant) .
Clinical Crown Lengthening (hard tissue).
Mucogingival Surgery (per quadrant) . . . . . . . . . . . . . . . . . . .
Osseous Surgery (including flap entry and closure; four or more contiguous teeth or
bounded teeth spaces per quadrant). . . . . . . . . . . . . . . . . . . . . . . . . . .
Osseous Surgery (including flap entry and closure; one to three teeth per quadrant)
Bone Replacement Graft (first site in quadrant) .
Bone Replacement Graft (each additional site in quadrant) . . . . . . . . . . . . . .
Pedicle Soft Tissue Graft Procedure . . . . . . . .
Free Soft Tissue Graft Procedure (including donor site surgery)
Subepithelial Connective Tissue Graft Procedures
Soft Tissue Allograft . .
Provisional Splinting (intracoronal). . . . . . . . . . . . . . .
Provisional Splinting (extracoronal) . . . . . . . . . . . . . . . . . . .
Periodontal Scaling and Root Planing (four or more contiguous teeth or bounded teeth
spaces per quadrant). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
D4342 Periodontal Scaling and Root Planing (one to three teeth per quadrant) ..
D4355 Full Mouth Debridement to Enable Comprehensive Evaluation and Diagnosis. .
04241
04249
D4250
D4260
04261
04263
D4264
04270
04271
04273
04275
04320
04321
04341
5-38
$ 15
15
40
45
45
150
200
250
250
130
180
225
130
30
65
140
275
300
110
80
160
120
55
$130
45
225
225
250
250
250
250
275
225
275
275
300
275
150
110
60
60
55
Dentures and Other Prosthetic Benefits
Benefits in this category are subject to a 24-month waiting peliod.
05110 Complete Denture (maxillary). . . . . . . . .
05120 Complete Denture (mandibular) ........
05130 Immediate Oenture (maxillary).
05140 Immediate Oenture (mandibular).
D5211 .Maxillary Partial Denture (resin base; including any conventional clasps, rests, and teeth)
D5212 Mandibular Partial Denture (resin base; including any conventional clasps, rests, and teeth)
D5213 Maxillary Partial Denture (cast metal framework with resin denture bases; including any
conventional clasps, rests, and teeth). . . . . . . . .
05214 Mandibular Partial Denture (cast metal framework with resin denture bases; including
any conventional clasps,. rests, and teeth) . . . . . . . ,. .....
Removable Unilateral Partial Denture (one-piece cast metal; including clasps and teeth)
Replace All Teeth and Acrylic on Cast Metal Framework (maxillary)
Replace All Teeth and Acrylic on Cast Metal Framework (mandibular)
Interim Complete Denture (maxillary) . . . . . . . . . . . . . . .
Interim Complete Denture (mandibular) . . . . . . . . . . . . . . .
Interim Partial Denture (maxillary) . . . . . . . . .
Interim Partial Denture (mandibular)
Surgical Placement oflmplant Body: Endosteal Implant.
Abutment Placement or Substitution: Endosteal Implant.
Surgical Placement: Eposteal Implant.
Surgic31 Placement: Transosteal Implant. . . .
Implant Maintenance Procedures, Including Removal of Prosthesis, Cleansing of
Prosthesis and Abutments, and Reinsertion of Prosthesis. .. ........
Pontic (cast high noble metal) .
Pontic (cast predominantly base metal).
Pontic (cast noble metal) . . . . . . . . . . . . . . . . . . . . . . .
Pontic (porcelain fused to high noblc mctal)
Pontic (porcelain fused to predominantly base metal).
Pomic (porcelain fused to noble metal) . . . . . . . . . . . .
Pontic (porcelain/ceramic).
Pontic (resin with high noble metal) . . . . . . . .
Pontic (resin with predominantly base metal) .
Pontic (resin with noble metal) . . . . .. ......
Provisional Pontic. . . . . . . . . . . . . . . .
Retainer (cast metal for resin-bonded fixed prosthesis) . .
Retainer (porcelain/ceramic for resin-bonded fixed prosthesis) .
Inlay (porcelain/ceramic, two surfaces) ...
Inlay (porcelain/ceramic, three or more surfaces)
Inlay (cast high noble metal, two surfaces)
Inlay (cast high noble metal, three or more surfaces)
Inlay (cast predominantly base metaL two surfaces) ......
Inlay (cast predominantly base metal, three or more surfaces)
Inlay (cast noble metal, two surfaces) . . . . . . . . . .
Inlay (cast noble metal, three or more surfaces) . . . . . . . . . .
OniJy (porcelain/ceramic, two surfaces) ..
Onlay (porcelain/ceramic, three or more surfaces) .
Onlay (cast high noble metal, two surfaces)
Onlay (cast high noble metal, three or more surfaces)
Oolay (cast predominantly base metal, two surfaces)
Onlay (cast predominantly base metal, three or more surfaces)
Onlay (cast noble metal, two surfaces) . . . . . . . . . . . .
Onlay (cast noble metal, three or more surfaces) . . . . . .. ............
Crown (resin with high noble metal). .
Crown (resin with predomin~mtly base metal).
Crown (resin with noble metal) .
05281
05670
05671
05810
05811
05820
05821
06010
06020
06040
06050
06080
06210
06211
06212
06240
06241
06242
06245
06250
06251
06252
06253
06545
06548
06600
06601
06602
06603
06604
06605
06606
06607
06608
06609
06610
06611
06612
06613
06614
06615
06720
06721
06722
5-39
$350
350
350
350
250
250
375
375
300
40
40
225
225
170
180
450
450
450
450
150
250
250
250
250
250
250
250
250
250
250
250
140
140
225
350
300
325
300
325
300
325
250
275
325
350
325
350
325
350
250
250
250
06740
06750
06751
06752
06780
06781
06782
06783
06790
06791
06792
06793
06970
06971
06972
06973
06975
Crown (porcelain/ceramic).
Crown (porcelain fused to high noble metal)
Crown (porcelain fused to predominantly base metal)
Crown (porcelain fused to noble metal). ...
Crown (3/4-cast high noble metal). . . . . . . . . . .
Crown (3/4-cast predominantly base metal) . .
Crown (3/4-cast noble metal). . . . .
Crown (3/4-porcelain/ceramic) . . . . . . . . . . . .
Crown (full-cast high noble metal) . . . .
Crown (full-cast predominantly base metal) . . . . . . . .
Crown (full-cast noble metal) . . . . . . . . . . . . . . . . . . . . .
Provisional Retainer Crown .. . . . . . . . . . . . . .
Cast Post and Core (in addition to fixed partial denture retainer).
Cast Post (as part of fixed partial denture retainer). . . . . . . . . . .
Prefabricated Post and Core (in addition to fixed partial denture retainer)
Core Buildup for RetaiI?er (including any pins)
Coping (metal) . . . . . . . . . . . . . . . . . . . . . . . . .
Repairs and Adjustments to Prosthetic Benefits
Benefits in this category are subject to a 6-month waiting period.
05410 Adjust Complete Denture (maxillary).......................
05411 Adjust Complete Denture (mandibular) . . . . . . . . . . . . . . . . . . . . .
05421 Adjust Partial Denture (maxillary) . . . . . . . . . . . . . .
05422 Adjust Partial Denture (mandibular) . . . . . . . . . . . . . . . .
05510 Repair Broken Complete Denture Base... ........
05520 Replace Missing or Broken Teeth (complete denture; each tooth) .
D5610 Repair Resin Denture Base .
05620 Repair Cast Framework. . .. ....
05630 Repair or Replace Broken Clasp. . . . . . . . . . . . . . . . . . . . .
05640 Replace Broken Teeth (per tooth) . . . . . . . . . . . . . . .
05650 Add Tooth to Existing Partial Denture. .
05660 Add Clasp to Existing Partial Denture ...
05710 Rebase Complete Maxillary Denture. . . . . . . . . . . . . . . . . . . . . .
05711 Rebase Complete Mandibular Denture. . . . . . . . . . . . . . . . . .
05720 Rebase Maxillary Partial Denture. . . . . . . . . . . . . . . . . . .
05721 Rebase Mandibular Partial Denture. . . . . . . . . . . . . . . . . . . . . .
D5730 Reline Complete Ma.xillary Denture (chairs ide) . . . . . . . . . .
05731 Reline Complete Mandibular Denture (chairside). . .
05740 Reline Maxillary Partial Denture (chairside).
05741 Reline Mandibular Partial Denture (chairside) . . . . . . . . . . . . . .
05750 Reline Complete Maxillary Denture (laboratory) .
05751 Reline Complete Mandibular Denture (laboratory).
05760 Reline Maxillary Partial Denture (laboratory). . . .
05761 Reline Mandibular Partial Denture (laboratory) . . . .
D5850 Tissue Conditioning (maxillary) .. ........
05851 Tissue Conditioning (mandibular). . . .. ..
06090 Repair of Implanted Supported Prosthetic, by Report.
06095 Repair of Implanted Abutment, by Report. .. ..............
06100 Implant Removal, by Report. . . . . . . . . .
D6930 Re(.;ement Fixed Partial Denture . . . . . . . . . .
Extractions and Other Oral Surgery Benefits
Benefits in this category are subject to a 6-month waiting period.
07111 Coronal Remnants (deciduous tooth) ... .......
07140 Extraction, Erupted Tooth or Exposed Root (elevation and/or forceps removal) .
D7210 Surgical Removal of Erupted Tooth Requiring Elevation of Mucoperiosteal Flap and
Removal of Bone and/or Section of Tooth. . . . . . . . . . . . . . .
5-40
250
250
250
250
250
250
250
250
250
250
250
250
130
120
100
85
225
$ 20
20
20
20
45
40
45
60
50
40
45
60
130
170
170
170
80
80
90
90
110
110
130
130
40
40
110
110
35
35
$ 35
40
70
D7220
D7230
D7240
D7241
D7250
D7260
D7270
D7230
D7231
D7232
D7235
D7286
D7310
D7320
D7340
D7350
D7410
D7411
D7412
D7413
D7414
D7415
D7440
D7441
D7450
D7451
D7460
D7461
D7471
D7472
D7473
D7435
D7510
D7520
07530
D7540
D7550
D7560
D7610
D7620
D7630
D7640
D7650
D7660
D7670
D7671
D7710
D7720
D7730
D7740
D7750
D7760
D 7770
Removal of Impacted Tooth (soft tissue)
Removal of Impacted Tooth (partially bony).
Removal of Impacted Tooth (completely bony).
Removal of Impacted Tooth (completely bony, with unusual surgical complications).
Surgical Removal of Residua[ Tooth Roots (cutting procedure).. ........
Oroantral Fistula Closure. . . . . . . .
Tooth Reimplantation and/or Stabilization of Accidentally Evulsed or Displaced Tooth
and/or Alveolus. . . . .
Surgical Access of an Unerupted Tooth.
Surgical Exposure of Impacted or Unerupted Tooth to Aid Eruption.
Mobilization of Erupted or Malpositioned Tooth to Aid Eruption.
Biopsy of Oral Tissue - Hard (bone, tooth).
Biopsy of Oral Tissue - Soft (all others).
Alveoloplasty in Conjunction \Vith Extractions (per quadrant)
Alveoloplasty Not in Conjunction \Vith Extractions (per quadrant).
Vestibuloplasty - Ridge Extension (secondary epithelialization)
Vestibuloplasty - Ridge Extension (including soft tissue grafts, muscle.: reattachment,
revision of soft tissue attachment, and management of hypertrophied and hyperplastic
tis~e)....... .......................
Excision of Benign Lesion (up to 1.25 em). . .
Excision of Benign Lesion (greater than 1.25 em) . . .
Excision of Benign Lesion (complicated).
Excision of Malignant Lesion (up to 1.25 cm)
Excision of Malignant Lesion (greater than 1.25 em).
Excision of Malignant Lesion (complicated). .. ..........
Excision of Malignant Tumor (lesion diameter up to 1.25 cm). . . . . . . . . . .
Excision of Malignant Tumor (lesion diameter greater than 1.25 em)
Removal of Benign Odontogenic Cyst or Tumor (lesion diameter up to 1.25 em).
Removal of Benign Odontogenic Cyst or Tumor (lesion diameter greater than 1.25 em)
Removal of Benign Nonodontogenic Cyst or Tumor (lesion diameter up to 1.25 cm).
Removal of Benign Nonodontogenic Cyst or Tumor (lesion diameter greater than
1.25 em) . . . . . . .. ........ . . . . . . . . .
Removal of Lateral Exostosis (maxilla or mandible) . . . . . . . . .
Removal of Torus Palatinus
Removal of Torus Mandibularis .........
Surgical Reduction of Osseous Tuberosity. . . . . .
Incision and Drainage of Abscess (intraoral soft tissue)
Incision and Drainage of Abscess (extraoral soft tissue).
Removal of Foreign Body From Mucosa, Skin, or Subcutaneous Alveolar Tissue
Removal of Reaction-Producing Foreign Bodies (musculoskeletal system).
Partial Ostectomy/Sequestrectomy for Removal of Non vital Bone. . .
Maxillary Sinusotomy for Removal of Tooth Fragment or Foreign Body
Maxilla (open reduction; teeth immobilized, if present) ..
Maxilla (closed reduction; teeth immobilized, ifpresent)...
Mandible (open reduction; teeth immobilized, if present).
Mandible (closed reduction; teeth immobilized, if present)
Malar and/or Zygomatic Arch (open reduction) .
Malar and/or Zygomatic Arch (closed reduction).
Alveolus (closed reduction, may include stabilization of teeth) ..
Alveolus (open reduction, may include stabilization of teeth) . . .
Ivlaxilla (open reduction) .
Maxilla (closed reduction).
Mandible (open reduction). .
Mandible ( closed reduction)
Malar and/or Zygomatic Arch (open reduction) .
Malar and/or Zygomatic Arch (closed reduction) .
Alveolus (open reduction stabilization of teeth) .
5-41
35
120
130
150
70
180
130
200
65
65
375
150
65
80
750
700
525
525
525
650
650
650
650
650
525
525
525
525
375
375
375
425
100
450
170
130
120
700
700
700
65
30
700
550
725
350
700
700
30
80
300
300
350
D7771
07960
07970
D7971
Alveolus (closed reduction stabilization of teeth) ... ........
Frenulectomy (frenectomy or frenotomy; separate procedure) . .
Excision of Hyperplastic Tissue (per arch) . . . . . . . . .
Excision of Pericoronal Gingiva
725
80
80
70
Pain Relief and Adjunctive Services Benefits
Benefits in this category are subject to a 3-month waiting period. Benefits D9220 and D9230 are not payable
for the same surgery.
D9110 Palliative (emergency) Treatment of Dental Pain (minor procedure) .........
D9220 Deep Sedation/General Anesthesia . . . . . . . . . .
D9230 Analgesia, Anxiolysis, Inhalation of Nitrous Oxide. . . . . . . . . .
D9241 Intravenous Conscious Sedation/Analgesia (first 30 minutes) . . . . . . . . .. .......
D9310 Consultation (diagnostic service provided by dentist or physician other than
practitioner providing treatment). . . . . . . . . . . . . . ... . .
House/Extended-Care Facility Call. .
Hospital Call
Office Visit (after regularly scheduled hours) .
Case Presentation, Detailed and Extensive Treatment Planning. .
D9410
D9420
D9440
D9450
Guaranteed-Renewable for Your Lifetime
This policy is guaranteed-renewable for your lifetime. subject
to Aflac's right to change premium rates for all policies of this
class.
Effective Date
The effective date of the policy will be the date shown in the
Policy Schedule, not the date the application is signed. This
policy is available through age 65 on payroll deduction and
age 64 on direct.
Family Coverage
Family coverage includes the insured; the insured's spouse;
and dependent, unmarried children to age 19 (age 23 if full-
time students). One-parent family coverage includes the
insured and dependent, unmarried children to age 19 (age 23
iffull-tirne students). Newborn children are automatically
covered from the moment of birth. A dependent child must be
under the age of 19 at the time of application to be eligible for
coverage.
The policy to which this sales material pertains is written
only in English; the policy prevails if interpretation of this
material varies.
$ 30
75
75
120
25
25
25
25
25
Exceptions, Reductions, and Limitations of This Policy
This policy does not cover losses caused by or resulting from
any procedure not shown on the Schedule of Dental
Procedures; services that are not recommended by a dentist or
that are not required for the preservation or restoration of oral
health; repairs to dental work within six months ofthe initial
work; replacement prosthetics within five years of last
placement; treatment involving crowns for a given tooth
within five years of last placement, regardless of the type of
crown; replacement for inlays or onlays for a given tooth
within five years of last placement; treatment received while
outside the territorial limits of the United States or, if outside
the United States, the territOliallimits of the place where your
policy was issued.
Benefits for sealants are limited to secondary molars for
dependent children under age 16 and will not be payable more
often than every five years. No benefits will be paid for
replacement of teeth missing before the effective date of
coverage. Benefits are not payable for procedures performed
by a member of your immediate family.
Waiting Period
This is the period after the effective date of coverage for
which benefits are not payable for each covered person. If a
dependent is added by endorsement, the waiting period will
begin from the effective date of the addition. In the event of
reinstatement, all covered persons will be subject to new
waiting periods begirming with the effective date of
reinstatement.
American Family Life ,'\ssuranc.: Company of Columbus (Aflac) Worldwide Heaciquartel s 1932 Wynnton Road Columbus, Georgia 31999 aflac.com
5-42
RESOLUTION NO. 2009-
RESOLUTION OF THE CITY COUNCIL OF THE CITY OF
CHULA VISTA APPROVING AN AGREEMENT BETWEEN
THE CITY OF CHULA VISTA AND AMERICAN FAMILY
LIFE ASSURANCE COMPANY OF COLUMBUS ("AFLAC")
TO OFFER VOLUNTARY INSURANCE COVERAGE TO ALL
BENEFITED EMPLOYEES, AUTHORIZING PRE-TAX
PAYROLL DEDUCTIONS FOR EMPLOYEES WHO ELECT
TO PURCHASE AFLAC SUPPLEMENTAL INSURANCE AND
AUTHORIZING THE MAYOR TO EXECUTE THE
AGREEMENT
WHEREAS, to accommodate the various benefit needs of City employees without added
cost to the City, staff recommends offering AFLAC as a voluntary insurance; and
WHEREAS, employee premium will be made through employee payroll deductions; and
WHEREAS, AFLAC will administer enrollment, billing reconciliation, claims processing
and claims payment for the City; and
WHEREAS, benefits arc paid directly to the employee; and
WHEREAS, founded in 1955, American Family Life Assurance Company (AFLAC)
currently has total assets of over $76 billion; and
WHEREAS, in 1958, AFLAC introduced an income protection insurance plan for people
diagnosed with cancer; and
WHEREAS, today, AFLAC policies include cancer, accident, short-term disability,
hospital confinement indemnity, life specified health event, dental, long-term care and vision;
and
WHEREAS, AFLAC has extensive experience working with the public sector; and
WHEREAS, the Deputy Sheriffs Association, City of San Diego, City of Escondido and
City of Los Angeles are some of their public sector clients; and
WHEREAS, currently, Chula Vista Employee Association ("CVEA") and Peace Ofiicers
Association (POA) members have access to AFLAC via their unions; and
WHEREAS, staff recommends that the City allow AFLAC to offer supplemental
insurance to all benefited employees, and that the City allows the premium be deducted trom
employee payroll on a pre-tax basis; and
5-43
Resolution No. 2009-
Page 2
WHEREAS, initially, the following policies will be available to eligible City employees:
(1) Personal Accident Indemnity, (2) Personal Cancer Indemnity Plan, (3) Specified Health
Event Protection, (4) Hospital Confinement Indemnity, (5) Personal Long-term Care, and (6)
Dental Basic; and
WHEREAS, premium rates will vary depending on the type of plan and level of coverage
an employee selects; and
WHEREAS, the City will periodically evaluate the above policies and determine if
additional voluntary policies should be made available; and
WHEREAS, the AFLAC voluntary insurance options will be offered to benefited
employees beginning January 1,2010.
NOW, THEREFORE, BE IT RESOLVED that the City Council of the City of Chula
Vista does hereby approve and Agreement between the City of Chula Vista and AFLAC to offer
voluntary insurance coverage to all benefited employees, authorize pre-tax payroll deductions for
employees who elect to purchase AFLAC supplemental insurance and authorize the Mayor to
execute the Agreement.
Presented by
Approved as to form by
~~-
Kelley Bacon
Director of Human Resources
Bart C. Miesfeld
City Attorney
5-44
ATTACHMENT B
Agreement between the
City of Chula Vista and AFLAC
5-45
THE ATTACHED AGREEMENT HAS BEEN REVIEWED
AND APPROVED AS TO FORtVI BY THE CrTY
ATTORNEY'S OFFICE AND WILL BE
FORMALL Y SlGNED UPON APPROVAL BY
THE CITY COUNCIL
~~
~--~~
Bart C Miesfeld
City Attorney
Dated: (0 ~ t) - () r
AGREEMENT BETWEEN THE CITY OF CHULA VISTA AND
AMERICAN FAMILY LIFE ASSURANCE COMPANY OF COLUMBUS
(AFLAC)
5-46
Parties and Recital Page(s)
Agreement between
CityofChula Vista
and
American Family Life Assurance Company of Columbus (AFLAC)
for the provision of voluntary insurance plans
This agreement (" Agreement"), dated October I, 2009 for the purposes of reference only,
and effective as of the date last executed unless another date is otherwise specified in Exhibit A,
Paragraph I, is between the City-related entity as is indicated on Exhibit A, Paragraph 2, as such
("City"), whose business form is set forth on Exhibit A, Paragraph 3, and the entity indicated on
the attached Exhibit A, Paragraph 4, as Consultant, whose business form is set forth on
Exhibit A, Paragraph 5, and whose place of business and telephone numbers are set forth on
Exhibit A, Paragraph 6 ("Consultant"), and is made with reference to the following facts:
Recitals
Whereas, the City and AFLAC desire to enter into an agreement for services;
Whereas AFLAC will provide selected voluntary insurance policies to City employees that
are 100% employee paid, subject to Aflac's receipt ofa signed application and underwriting;
Whereas currently, CVEA and POA members have access to AFLAC voluntary insurance
policies through their labor unions;
Whereas AFLAC policies will be offered to all benefited City employees on a pre-tax basis;
Whereas the AFLAC voluntary insurance options will be offered to benefited employees
beginning January 1, 2010;
Whereas l\FLAC warrants and represents that they are experienced and staffed such in a
manner that they are and can prepare to deliver the services required of AFLAC to the City
within timeframes provided by the City, in accordance with terms and conditions of this
Agreement.
(End of Recitals. Next Page starts Obligatory Provisions.)
5-47
Page I
Obligatory Provisions Pages
NOW, THEREFORE, BE IT RESOLVED that the City and Consultant do hereby mutually
agree as follows:
1. Consultant's Duties
A. General Duties
Consultant shall perform all of the services described on the attached Exhibit A, Paragraph 7,
entitled "General Duties"; and,
B. Scope of Work and Schedule
In the process of performing and delivering said "General Duties", Consultant shall also
perform all of the services described in Exhibit A, Paragraph 8, entitled "Scope of Work and
Schedule", not inconsistent with the General Duties, according to, and within the time frames set
forth in Exhibit A, Paragraph 8, and deliver to City such Deliverables as are identified in Exhibit
A, Paragraph 8, within the time frames set forth therein, time being of the essence of this
agreement. The General Duties and the work and deliverables required in the Scope of Work and
Schedule shall be herein referred to as the "Defined Services". Failure to complete the Defined
Services by the times indicated does not, except at the option of the City, operate to terminate
this Agreement.
C. Reductions in Scope of Work
City may independently, or upon request from Consultant, from time to time reduce the
Defined Services to be performed by the Consultant under this Agreement. Upon doing so, City
and Consultant agree to meet in good faith and confer for the purpose of negotiating a
corresponding reduction in the compensation associated with said reduction.
D. Additional Services
In addition to performing the Defined Services herein set forth, City may require Consultant
to perform additional consulting services related to the Defined Services ("Additional Services"),
and upon doing so in writing, if they are within the scope of services offered by Consultant,
Consultant shall perform same on a time and materials basis at the rates set forth in the "Rate
Schedule" in Exhibit A, Paragraph lO(C), unless a separate fixed fee is otherwise agreed upon.
All compensation for Additional Services shall be paid monthly as billed.
E. Standard of Care
Consultant, in performing any Services under this agreement, whether Defined Services or
Additional Services, shall perform in a marmer consistent with that level of care and skill
ordinarily exercised by members of the profession currently practicing under similar conditions
and in similar locations.
5-48
Page 2
F. Insurance
Consultant must procure insurance against claims for injuries to persons or damages to
property that may arise from or in connection with the performance ofthe work under the
contract and the results of that work by the Consultant, his agents, representatives, employees or
subcontractors and provide documentation of same prior to commencement of work. The
insurance must be maintained for the duration of the contract.
Minimum Scope ofTnsurance
Coverage must be at least as broad as:
(I) Insurance Services OtDce Commercial General Liability coverage (occurrence Form
CGOOOI).
(2) Insurance Services Office Form Number CA 0001 covering Automobile Liability,
Code 1 (any auto).
(3) Workers' Compensation insurance as required by the State of Cali fomi a and
Employer's Liability Insurance.
(4) Professional Liability or Errors & Omissions Liability insurance appropriate to the
Consultant's profession. Architects' and Engineers' coverage is to be endorsed to
include contractual liability. Aflac is self-insured for Professional Liability
Insurance. Aflac's independent agents for whom Aflac is not liable, shall each have
his or her own individual E & 0 policy.
Minimum Limits ofInsurance
Contractor must maintain limits no less than:
1. General Liability:
(Including operations,
products and completed
operations, as applicable)
2. Automobile Liability:
3. Workers' Compensation
Employer's Liability:
4. Professional Liability or
Errors & Omissions
Liability:
$1,000,000 per occurrence for bodily injury, personal injury and
property damage. If Commercial General Liability insurance
with a general aggregate limit is used, either the general
aggregate limit must apply separately to this project/location or
the general aggregate limit must be twice the required occurrence
limit.
$1,000,000 per accident for bodily injury and property damage.
Statutory
$1,000,000 each accident
$1,000,000 disease-policy limit
$1,000,000 disease-each employee
Each individual agent providing services to the City on behalf of
AFLAC maintain evidence of coverage for E&O Policies.
5-49
Page 3
Deductibles and Self-Insured Retentions
Any deductibles or self-insured retentions must be declared to and approved by the City. At
the option of the City, either the insurer will reduce or eliminate such deductibles or self-insured
retentions as they pertain to the City, its officers, officials, employees and volunteers; or the
Consultant will provide a financial guarantee satisfactory to the City guaranteeing payment of
losses and related investigations, claim administration, and defense expenses.
Other Insurance Provisions
The general liability, automobile liability, and where appropriate, the worker's compensation
policies are to contain, or be endorsed to contain, the following provisions:
(1) The City of Chula Vista, its officers, officials, employees, agents, and volunteers are
to be named as additional insureds with respect to liability arising out of automobiles
owned, leased, hired or borrowed by or on behalf of the Consultant, where applicable,
and, with respect to liability arising out of work or operations performed by or on
behalf of the Consultant, including providing materials, parts or equipment furnished
in connection with such work or operations. The general liability additional insured
coverage must be provided in the form of an endorsement to the contractor's
insurance using ISO CG 2010 (11/85) or its equivalent. Specifically, the endorsement
must not exclude Products/Completed Operations coverage.
(2) The Consultant's General Liability insurance coverage must be primary insurance as
it pertains to the City, its officers, officials, employees, agents, and volunteers. Any
insurance or self-insurance maintained by the City, its officers, officials, employees,
or volunteers is wholly separate from the insurance of the contractor and in no way
relieves the contractor from its responsibility to provide insurance.
(3) The insurance policy required by this clause must be endorsed to state that coverage
will not be canceled by either party, except after thirty (30) days' prior written notice
to the City by certified mail, return receipt requested.
(4) Coverage shall not extend to any indemnity coverage for the active negligence of the
additional insured in any case where an agreement to indemnify the additional insured
would be invalid under Subdivision (b) of Section 2782 of the Civil Code.
(5) Consultant's insurer will provide a Waiver of Subrogation in favor of the City for
each required policy providing coverage during the life ofthis contract.
If General Liability, Pollution and/or Asbestos Pollution Liability and/or Errors & Omissions
coverage are written on a claims-made form:
5-50
Page 4
(1) The "Retro Date" must be shown, and must be before the date of the contract or the
beginning of the contract work.
(2) Insurance must be maintained and evidence 0 f insurance must be provided for at least
five (5) years after completion of the contract work.
(3) If coverage is canceled or non-renewed, and not replaced with another claims-made
policy form with a "Retro Date" prior to the contract effective date, the Consultant
must purchase "extended reporting" coverage for a minimum of five (5) years after
completion of contract work.
(4) A copy of the claims reporting requirements must be submitted to the City for review.
Acceptability of Insurers
Insurance is to be placed with licensed insurers admitted to transact business in the State of
California with a current A.M. Best's rating of no less than A-. If insurance is placed with a
surplus lines insurer, insurer must be listed on the State of California List of Eligible Surplus
Lines Insurers ("LESLI") with a current A.M. Best's rating of no less than A X. Exception may
be made for the State Compensation Flmd when not specifically rated.
Verification of Coverage
Consultant shall furnish the City with original certificates and amendatory endorsements
effecting coverage required by this clause. The endorsements should be on insurance industry
forms, provided those endorsements or policies conform to the contract requirements. All
certificates and endorsements are to be received and approved by the City before work
commences. The City reserves the right to require, at any time, complete, certified copies of all
required insurance policies, including endorsements evidencing the coverage required by these
specifications.
Subcontractors
Consultants must include all sub consultants as insureds under its policies or furnish separate
certificates and endorsements for each subconsultant. All coverage for subconsultants are subject
to all of the requirements included in these specifications. Aflac's independent agents will each
have his or her own insurance.
G. Security for Performance
(1) Performance Bond
In the event that Exhibit A, at Paragraph 18, indicates the need for Consultant to provide
a Performance Bond (indicated by a check mark in the parenthetical space immediately
preceding the subparagraph entitled "Performance Bond"), then Consultant shall provide to the
City a performance bond in the form prescribed by the City and by such sureties which are
authorized to transact such business in the State of California, listed as approved by the United
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States Department of Treasury Circular 570, htto:l/www.fms.treas.gov/c570, and whose
underwriting limitation is sufficient to issue bonds in the amount required by the agreement, and
which also satisfy the requirements stated in Section 995.660 of the Code of Civil Procedure,
except as provided otherwise by laws or regulations. All bonds signed by an agent must be
accompanied by a certified copy of such agent's authority to act. Surety companies must be duly
licensed or authorized in the jurisdiction in which the Project is located to issue bonds for the
limits so required. Form must be satisfactory to the Risk Manager or City Attorney which
amount is indicated in the space adjacent to the term, "Performance Bond", in said Exhibit A,
Paragraph 18.
(2) Letter of Credit
In the event that Exhibit A, at Paragraph 18, indicates the need for Consultant to provide
a Letter of Credit (indicated by a check mark in the parenthetical space immediately preceding
the subparagraph entitled "Letter of Credit"), then Consultant shall provide to the City an
irrevocable letter of credit callable by the City at their unfettered discretion by submitting to the
bank a letter, signed by the City Manager, stating that the Consultant is in breach of the terms of
this Agreement. The letter of credit shall be issued by a bank, and be in a form and amount
satisfactory to the Risk Manager or City Attorney which amount is indicated in the space
adjacent to the term, "Letter of Credit", in said Exhibit A, Paragraph 18.
(3) Other Security
In the event that Exhibit A, at Paragraph 18, indicates the need for Consultant to provide
security other than a Performance Bond or a Letter of Credit (indicated by a check mark in the
parenthetical space immediately preceding the subparagraph entitled "Other Security"), then
Consultant shall provide to the City such other security therein listed in a form and amount
satisfactory to the Risk Manager or City Attorney.
H. Business License
Consultant agrees to obtain a business license from the City and to otherwise comply with
Title 5 of the Chula Vista Municipal Code.
2. Duties of the City
A. Consultation and Cooperation
City shall regularly consult the Consultant for the purpose of reviewing the progress of the
Defined Services and Schedule therein contained, and to provide direction and guidance to
achieve the objectives afthis agreement. The City shall permit access to its office facilities, files
and records by Consultant throughout the term of the agreement. In addition thereto, City agrees
to provide the information, data, items and materials set forth on Exhibit A, Paragraph 9, and
with the further understanding that delay in the provision of these materials beyond thirty (30)
days after authorization to proceed, shall constitute a basis for the justifiable delay in the
Consultant's performance of this agreement.
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B. Compensation
Upon receipt of a properly prepared billing from Consultant submitted to the City
periodically as indicated in Exhibit A, Paragraph 17, but in no event more frequently than
monthly, on the day of the period indicated in Exhibit A, Paragraph 17, City shall compensate
Consultant for all services rendered by Consultant according to the terms and conditions set forth
in Exhibit A, Paragraph 10, adjacent to the governing compensation relationship indicated by a
"checkmark" next to the appropriate arrangement, subject to the requirements for retention set
torth in Paragraph 18 of Exhibit A, and shall compensate Consultant for out ofpocket expenses
as provided in Exhibit A, Paragraph 11.
All billings submitted by Consultant shall contain sufficient information as to the propriety of
the billing to permit the City to evaluate that the amount due and payable thereunder is proper,
and shall specifically contain the City's account number indicated on Exhibit A, Paragraph 17(C)
to be charged upon making such payment.
3. Administration of Contract
Each party designates the individuals ("Contract Administrators") indicated on Exhibit A,
Paragraph 12, as said party's contract administrator who is authorized by said party to represent
them in the routine administration of this agreement.
4. Term
This Agreement shall terminate when the Parties have complied with all executory provisions
hereof.
5. Liquidated Damages
The provisions of this section apply if a Liquidated Damages Rate is provided in Exhibit A,
Paragraph 13.
It is acknowledged by both parties that time is of the essence in the completion of this
Agreement. It is difIicult to estimate the amount of damages resulting from delay in
performance. The parties have used their judgment to arrive at a reasonable amount to
compensate for delay.
Failure to complete the Defmed Services within the allotted time period specified in this
Agreement shall result in the following penalty: For each consecutive calendar day in excess of
the time specified for the completion ofthe respective work assignment or Deliverable, the
Consultant shall pay to the City, or have withheld from monies due, the sum of Liquidated
Damages Rate provided in Exhibit A, Paragraph 13 ("Liquidated Damages Rate").
Time extensions for delays beyond the Consultant's control, other than delays caused by the
City, shall be requested in writing to the City's Contract Administrator, or designee, prior to the
expiration of the specified time. Extensions of time, when granted, will be based upon the effect
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of delays to the work and will not be granted for delays to minor portions of work unless it can
be shown that such delays did or will delay the progress of the work.
6. Financial Interests of Consultant
A. Consultant is Designated as an FPPC Filer
If Consultant is designated on Exhibit A, Paragraph 14, as an "FPPC filer", Consultant is
deemed to be a "Consultant" for the purposes of the Political Reform Act conflict of interest and
disclosure provisions, and shall report economic interests to the City Clerk on the required
Statement of Economic Interests in such reporting categories as are specified in Paragraph 14 of
Exhibit A, or if none are specified, then as determined by the City Attorney.
B. Decline to Participate
Regardless of whether Consultant is designated as an FPPC Filer, Consultant shall not make,
or participate in making or in any way attempt to use Consultant's position to influence a
governmental decision in which Consultant knows or has reason to know Consultant has a
[mancial interest other than the compensation promised by this Agreement.
C. Search to Determine Economic Interests
Regardless of whether Consultant is designated as an FPPC Filer, Consultant warrants and
represents that Consultant has diligently conducted a search and inventory of Consultant's
economic interests, as the term is used in the regulations promulgated by the Fair Political
Practices Commission, and has determined that Consultant does not, to the best of Consultant's
knowledge, have an economic interest which would conflict with Consultant's duties under this
agreement.
D. Promise Not to Acquire Conflicting Interests
Regardless of whether Consultant is designated as an FPPC Filer, Consultant further warrants
and represents that Consultant will not acquire, obtain, or assume an economic interest during the
term ofthis Agreement which would constitute a conflict of interest as prohibited by the Fair
Political Practices Act.
E. Duty to Advise of Conflicting Interests
Regardless of whether Consultant is designated as an FPPC Filer, Consultant further warrants
and represents that Consultant will immediately advise the City Attorney of City if Consultant
learns of an economic interest of Consultant's that may result in a conflict of interest for the
purpose of the Fair Political Practices Act, and regulations promulgated thereunder.
F. Specific Warranties Against Economic Interests
Consultant warrants and represents that neither Consultant, nor Consultant's immediate
family members, nor Consultant's employees or agents ("Consultant Associates") presently have
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any interest, directly or indirectly, whatsoever in any property which may be the subject matter
of the Defined Services, or in any property within 2 radial miles from the exterior bOlmdaries of
any property which may be the subject matter of the Defined Services, ("Prohibited Interest"),
other than as listed in Exhibit A, Paragraph 14.
Consultant further warrants and represents that no promise ofUlhlre employment,
remuneration, consideration, gratuity or other reward or gain has been made to Consultant or
Consultant Associates in connection with Consultant's performance ofthis Agreement.
Consultant promises to advise City 0 f any such promise that may be made during the Term of
this Agreement, or for twelve months thereafter.
Consultant agrees that Consultant Associates shall not acquire any such Prohibited Interest
within the Term ofthis Agreement, or for twelve months after the expiration ofthis Agreement,
except with thc written permission of City.
Consultant may not conduct or solicit any business for any party to this Agreement, or for
any third party that may be in conflict with Consultant's responsibilities under this Agreement,
except with the written permission of City.
7. Hold Harmless
Consultant shall defend, indemnify, protect and hold harmless the City, its elected and
appointed officers and employees, from and against all claims for damages, liability, cost and
expense (including without limitation attorneys fees) arising out of or alleged by third parties
arising as a result of the administration ofthis Agreement, the actions of Consultant, and
Consultant's employees, subcontractors or other persons, agencies or firms for whom Consultant
is legally responsible in connection with the execution of the work covered by this Agreement,
except only for those claims, damages, liability, costs and expenses (including without
limitations, attorneys fees) arising from the sole negligence or sole willful misconduct of the
City, its officers, employees. Also covered is liability arising from, connected with, caused by or
claimed to be caused by the active or passive negligent acts or omissions of the City, its agents,
officers, or employees which may be in combination with the active or passive negligent acts or
omissions of the Consultant, its employees, agents or officers, or any third party.
With respect to losses arising from Consultant's professional errors or omissions, Consultant
shall defend, indemnify, protect and hold harmless the City, its elected and appointed officers
and employees, from and against all claims for damages, liability, cost and expense (including
without limitation attorneys fees) except for those claims arising from the negligence or willful
misconduct of City, its officers or employees.
Consultant's indemnification shall include any and all costs, expenses, attorneys fees and
liability incurred by the City, its officers, agents or employees in defending against such claims,
whether the same proceed to judgment or not. Consultant's obligations under this Section shall
not be limited by any prior or subsequent declaration by the Consultant. Consultant's obligations
under this Section shall survive the termination of this Agreement.
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For those professionals who are required to be licensed by the state (e.g. architects, landscape
architects, surveyors and engineers), the following indemnification provisions should be utilized:
(1) Indemnification and Hold Harmless Agreement
With respect to any liability, including but not limited to claims asserted or costs, losses,
attorney fees, or payments for injury to any person or property caused or claimed to be caused by
the acts or omissions ofthe Consultant, or Consultant's employees, and officers, arising out of
any services performed involving this project, except liability for Professional Services covered
under Section 7.2, the Consultant agrees to defend, indemnify, protect, and hold harmless the
City, its agents, officers, or employees from and against all liability. Also covered is liability
arising from, connected with, caused by, or claimed to be caused by the active or passive
negligent acts or omissions of the City, its agents, officers, or employees which may be in
combination with the active or passive negligent acts or omissions of the Consultant, its
employees, agents or officers, or any third party. The Consultant's duty to indemnify, protect and
hold harmless shall not include any claims or liabilities arising from the sole negligence or sole
willful misconduct of the City, its agents, officers or employees. This section in no way alters,
affects or modifies the Consultant's obligation and duties under Section Exhibit A to this
Agreement.
(2) Indemnification for Professional Services.
As to the Consultant's professional obligation, work or services involving this Project,
the Consultant agrees to indemnify, defend and hold harmless the City, its agents, officers and
employees from and against any and all liability, claims, costs, and damages, including but not
limited to, attorneys fees, that arise out of, or pertain to, or relate to the administration of this
Agreements and the actions of Consultant and its employees in the performance of services
under this agreement, but this indemnity does not apply liability for damages for death or bodily
injury to persons, injury to property, or other loss, arising from the sole negligence, willful
misconduct or defects in design by City or the agents, servants, or independent contractors who
are directly responsible to City, or arising from the active negligence of City.
8. Termination of Agreement for Cause
If, through any cause, Consultant shall fail to fulfill in a timely and proper manner
Consultant's obligations under this Agreement, or if Consultant shall violate any of the
covenants, agreements or stipulations of this Agreement, City shall have the right to terminate
this Agreement by giving written notice to Consultant of such termination and specifying the
effective date thereof at least five (5) days before the effective date of such termination. In that
event, all finished or unfinished documents, data, studies, surveys, drawings, maps, reports and
other materials prepared by Consultant shall, at the option of the City, become the property of the
City, and Consultant shall be entitled to receive just and equitable compensation for any work
satisfactorily completed on such documents and other materials up to the effective date of Notice
of Termination, not to exceed the amounts payable hereunder, and less any damages caused City
by Consultant's breach.
9. Errors and Omissions
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In the event that it is adjudicated by a court that the Consultants' negligence, errors, or
omissions in the performance of work under this Agreement has resulted in expense to City
greater than would have resulted ifthere were no such negligence, errors, omissions, Consultant
shall reimburse City for any additional expenses incurred by the City. Nothing herein is intended
to limit City's rights under other provisions ofthis agreement.
10. Termination of Agreement for Convenience of City
City may terminate this Agreement at any time and for any reason, by giving specific written
notice to Consultant of such tennination and specifying the effective date thereof, at least thirty
(30) days before the effective date of such termination. In that event, all finished and unfinished
documents and other materials described hereinabove shall, at the option of the City, become
City's sole and exclusive property. If the Agreement is terminated by City as provided in this
paragraph, Consultant shall be entitled to receive just and equitable compensation for any
satisfactory work completed on such documents and other materials to the effective date of such
termination. Consultant hereby expressly waives any and all claims for damages or
compensation arising under this Agreement except as set forth herein.
11. Assignability
The services of Consultant are personal to the City, and Consultant shall not assign any
interest in this Agreement, and shall not transfer any interest in the same (whether by assignment
or notation), without prior written consent of City.
City hereby consents to the assignment of the portions of the Defined Services identified in
Exhibit A, Paragraph 16 to the subconsultants identified thereat as "Permitted Subconsultants".
12. Ownership, Publication, Reproduction and Use of Material
All reports, studies, information, data, statistics, forms, designs, plans, procedures, systems
and any other materials or properties produced under this Agreement shall be the sole and
exclusive property of City. No such materials or properties produced in whole or in part under
this Agreement shall be subject to private use, copyrights or patent rights by Consultant in the
United States or in any other country without the express written consent of City. City shall have
unrestricted authority to publish, disclose (except as may be limited by the provisions of the
Public Records Act), distribute, and otherwise use, copyright or patent, in whole or in part, any
such reports, studies, data, statistics, forms or other materials or properties produced under this
Agreement.
13. Independent Contractor
City is interested only in the results obtained and Consultant shall perform as an independent
contractor with sole control of the manner and means of performing the services required under
this Agreement. City maintains the right only to reject or accept Consultant's work products.
Consultant and any of the Consultant's agents, employees or representatives are, for all purposes
under this Agreement, an independent contractor and shall not be deemed to be an employee of
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City, and none of them shall be entitled to any benefits to which City employees are entitled
including but not limited to, overtime, retirement benefits, worker's compensation benefits,
injury leave or other leave benefits. Therefore, City will not withhold state or federal income tax,
social security tax or any other payroll tax, and Consultant shall be solely responsible for the
payment of same and shall hold the City harmless with regard thereto.
14. Administrative Claims Requirements and Procedures
No suit or arbitration shall be brought arising out of this agreement, against the City unless a
claim has first been presented in writing and filed with the City and acted upon by the City in
accordance with the procedures set forth in Chapter 1.34 of the Chula Vista Municipal Code, as
same may from time to time be amended, the provisions of which are incorporated by this
reference as if fully set forth herein, and such policies and procedures used by the City in the
implementation of same.
Upon request by City, Consultant shall meet and confer in good faith with City for the
purpose of resolving any dispute over the terms of this Agreement.
15. Attorney's Fees
Should a dispute arising out of this Agreement result in litigation, it is agreed that the
prevailing party shall be entitled to a judgment against the other for an amount equal to
reasonable attorney's fees and court costs incurred. The "prevailing party" shall be deemed to be
the party who is awarded substantially the relief sought.
16. Statement of Costs
In the event that Consultant prepares a report or document, or participates in the preparation
of a report or document in performing the Defmed Services, Consultant shall include, or cause
the inclusion of, in said report or document, a statement of the numbers and cost in dollar
amounts of all contracts and subcontracts relating to the preparation of the report or document.
17. Miscellaneous
A. Consultant not authorized to Represent City
Unless specifically authorized in writing by City, Consultant shall have no authority to act as
City's agent to bind City to any contractual agreements whatsoever.
B. Consultant is Real Estate Broker and/or Salesman
If the box on Exhibit A, Paragraph 15 is marked, the Consultant and/or their principals is/are
licensed with the State of California or some other state as a licensed real estate broker or
salesperson. Otherwise, Consultant represents that neither Consultant, nor their principals are
licensed real estate brokers or salespersons.
C. Notices
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All notices, demands or requests provided for or permitted to be given pursuant to this
Agreement must be in writing. All notices, demands and requests to be sent to any party shall be
deemed to have been properly given or served if personally served or deposited in the United
States mail, addressed to such party, postage prepaid, registered or certified, with return receipt
requested, at the addresses identified herein as the places of business for each of the designated
parties.
D. Entire Agreement
This Agreement, together with any other written document referred to or contemplated
herein, embody the entire Agreement and understanding between the parties relating to the
subject matter hereof. Neither this Agreement nor any provision hereof may be amended,
modified, waived or discharged except by an instrument in writing executed by the party against
which enforcement of such amendment, waiver or discharge is sought.
E. Capacity of Parties
Each signatory and party hereto hereby warrants and represents to the other party that it has
legal authority and capacity and direction from its principal to enter into this Agreement, and that
all resolutions or other actions have been taken so as to enable it to enter into this Agreement.
F. Governing LawNenue
This Agreement shall be governed by and construed in accordance with the laws of the State
of California. Any action arising under or relating to this Agreement shall be brought only in the
federal or state courts located in San Diego County, State of California, and if applicable, the
City of Chula Vista, or as close thereto as possible. Venue for this Agreement, and performance
hereunder, shall be the City ofChula Vista.
(End of page. Next page is signature page.)
5-59
Page 13
Signature Page
to
Agreement between
City of Chula Vista
and
[American Family Life Assurance Company of Columbus (AFLAC)]
for the provision ofvoluntarv insurance plans
IN WITNESS WHEREOF, City and Consultant have executed this Agreement thereby
indicating that they have read and understood same, and indicate their full and complete consent
to its terms:
Dated:
City of Chula Vista
By:
Cheryl Cox, Mayor
Attest:
Donna Norris, City Clerk
Approved as to form:
Bart Miesfeld, City Attorney
Dated: October 2. 2009
[ AFLAC]
By:~~
[Deborah B. Griffin, Second
President]
By:
[Name of Person, Title]
Exhibit List to Agreement
(X ) Exhibit A.
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Page 14
Exhibit A
to
Agreement between
City of Chula Vista
and
American Family Life Assurance Company of Columbus (AFLAC)
1. Effective Date of Agreement:
January L 2010
2. City-Related Entity:
(X )City of Chula Vista, a municipal chartered corporation of the State of California
( ) Redevelopment Agency of the City ofChula Vista, a political subdivision of the State of
California
( ) Industrial Development Authority of the City of Chula Vista, a
( )Other:
, an msurance company.
("City")
3. Place of Business for City:
City of Chula Vista
276 Fourth Avenue
Chula Vista, CA 91910
4. Consultant: Tessa Goetz-Munster, is an independent agent representing AFLAC. She will
serve as the City's local consultant for all account emollment and servicing.
5. Business Form of Consultant:
AFLAC is a:
( ) Sole Proprietorship
( ) Partnership
( X) Corporation
6. Place of Business, Telephone and Fax Number of Consultant:
1947 Camino Vida Roble, Suite 106
Carlsbad, California 92008
Voice Phone: (760) 443-6641
Fax Phone: (760) 607-0868
AFLAC Worldwide Headquarters
1932 Wynnton Road
Columbus, GA 31999
Voice Phone: 1-800-992-3522
Fax Phone: (706) 320-4659
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Page 15
7. General Duties: Account enrollment with regard to AFLAC products for voluntary City
employee plans including Accident Indemnity Plan, Cancer, Specified Health Event, Hospital
Protection, Dental (Basic Only) and Long-Term Care plans and ongoing account servicing which
involves meeting with the employer/owner, payroll specialists, policyholders, claimants, and new
employees. Servicing also includes handling upgrades, conversions, re-enrollment, and helping
with claims and billing issues.
8. Scope of Work and Schedule:
. Provide informational meetings to employees at open enrollment period.
. Store employee information related to enrollment and administration of voluntary plans.
. Provide a toll-free service number to employees and on-line account services.
. Provide marketing materials to the City for new hire orientation and open enrollment.
. Respond to reasonable inquiries by employees of the City about their coverage and the
procedure for submission of claims.
. Use reasonable care to guard against fraudulent or erroneous payments.
. Send biweekly invoices to the City ofChula Vista.
. Monitor and reconcile the receipt of employee premiums remitted by the City.
. Collect any missed deductions from an employee.
. Maintain records and accounts of the insurance plans' operation.
. Coordinate benefit payments to participants, including the provision of required tax
filings in regard to these payments.
. Perform periodic accounting of employee contributions and benefit payments.
. Give the City rights to access City records for auditing purposes.
. Maintain strict compliance with federal law with regard to performance of administrative
duties.
. Meet with City staff on an annual basis to review products, and discuss services
. Keep the City abreast of proposed and enacted legislation and regulations that affect
AFLAC voluntary plans offered to City employees.
B. Date for Commencement of Consultant Services:
( X) Same as Effective Date of Agreement
( ) Other:
C. Dates or Time Limits for Delivery ofDeliverables:
Deliverable No. I: N/A
Deliverable No. 2: N/A
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Page 16
Deliverable No.3: N/A
D. Date for completion of all Consuliant services: until agreement is terminated
5-63
Page 17
9. Materials Required to be Supplied by City to Consultant: None
10. Compensation:
.'\. ( ) Single Fixed Fee .^.rrangement.~
For performance of all of the Defined Services by Consultant as herein required, City shall
pay a single filled fee in the ameunts and at the times or milestenes or for the Delivenwles set
forth below:
Single Fi:;ea Fee .^.mount:
, payable as fullows:
Milestone or Event or Deliverable
.'\mount or Percent ofFil;ed Fee
( ) 1. Interim ~'!onthly ."'dvances. The City shall make interim monthly aavances
against the compensation due f-or each phase on a percentage of completion basis for
each gi'len phase such that, at the end of each phase omy the compensation for that
phase has been paid. .'\ily pa)IDents made hereunder shall be considered as interest
froe loans that must be returned to the City if tRe Phase is not satisfactorily
completed. If the PRase is satisfactorily completed, the City shan receive credit
against the compensation dHe for that phase. The retention amoHat or percoatage set
forth in Para;raph 19 is to be applied to each interim payment "uch that, at the ena of
the phase, the nlll retention has been held back from the compensation aue f-or that
phase. Percentage of completicm of a phase shall be assessed in the sole and
uafettered discretion by the Contracts .^.dministrator designated Rerein by the City, or
such other person as the City M:anager shall desi;nate, bHt only Hpon such proof
demanded by the City that has been pro';ided, but in no event shall such interim
ach'ance payment be made unless the Contractor shall have representea in writing that
said percentage of completion of the phase has been performed by the Contractor.
The practice of making interim monthly advances shall not convert this a;reement to
a time and materials basis of pa)ment.
B. ( ) Phased Fixed Fee .'\rrangemont.
For the performance of eaeh phase or portioa of the Definea Services by Consultaat as are
separately identified belo'.v, City shall pay the fixed fee associated with eaeh phase of Servicos,
3. The difference between a sint;le fi~;ed fee amount with phased payments aad a phased fixed
f~e amount is that, in a siagb filced fee amount all of the ,,;ork is required fer all of the
compensation. Pa)m~ats are phased to help with eonsHltant eash flow. In a phased fixed fee
arrangement, the City has the authority to eaaed or require performance Hnaer subsequent
phases, so that the compensation is due jHst f-or tRe phase of '.vork required, and not for the
total amount.
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Page 18
in the amolmts and at the timos or milestones or Deliverabbs set forth. Consultant shall not
commcnce Ser:ices andor any Phase, and shall not b3 entitled to the compensation for a Phase,
anlzss City shall ha':e issHcd a notice to proceed to Consultant as to said Phase.
Phase
-h
:&.
Fee for Said Phase
~
or.
$
$
$
AFLAC agents and brokers are compensated by the sale of their voluntary insurance plans. They
are paid a set commission depending on the voluntary plan and the type of contract the agent
and/or broker has with AFLAC. In order to receive commissions, all personnel must be licensed
in that state and appointed by AFLAC.
( ) I. Interim Monthly i\dvances. The City shall make interim monthly advances
abainst the compensation dHe for each phase on a percentabe of completion basis f{)r
each bi':en phase s,wa that, at the end of each phase only the compeRsation for that
phase has been paid. .^.ny paiments made h3reunder shall be considered as interest
fFee-kJans taat must be returned to the City if the Phase is not satisfactorily
completed. Iftha Phase is satisfactorily completed, the City shall receive credit
abainst the compensation due for that phase. The retention amount or percentabe set
forth in Parab'faph 19 is to be applicd to each interim payment such that, at the end of
the phase, the full retention has been held bac!; from the compensation due for that
phase. Percentabc of completion of a phase shall be asscssed in tho sole and
unfettered discretion by the Contracts ;\dministrator desi<;nated herein by the City, or
such other person as the City Manaber shall desi;nate, but only upon such proof
oomanded by the City that has been pro'lided, but in no e':ent shall such interim
advance paiment be made anless the Contractor shall have represented in writin; that
said percenta;e of completion of the phase has been performed by the Contractor.
The practice ofmabnb interim monthly advances shall not convert this agreement to
a time and mat3rials basis ofpayment.
C. ( ) Hourly Rate Arrangement
With the exception of question 18, Section C is not applicable to AFLAC
For performance ofrhe Dzfined Services by Consultant as hzrein reqaired, City shall pay
Consultant for the prodactiye hours of time_spent by Consultant in the performance of said
Services, at rhe rates or amounts set forth in the R~to SehedHle herein below according to tho
follo',';ing terms and conditions:
(1) ( ) 1';ot to E][eeed Limitation on Time and l\'faterials ;\rranbomont
Not:/ithstandinb the expendituro by Consultant of time and materials in excess of said
Maximum. Comp3nsation amount, Consultant a;reos that Consultant will perform all of
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the Definecl Sar/iees herein requirecl of Consultant for S
including all Materials, and other "rcimbursables" ("Maximum Cempensatioa").
(2) ( ) Limitatioa without Further },uthorization on Time and Materials .-\rrangemant
},t such time as Consultaat shall ha'/e ineurrccl time and materials equal to
E" A HIR . I' T' . "\ f"'
. . .. onza IOn LImIt J, ~oasultaat shall not be entitled
to ony addlhonal compensation without further authorizatiofl issuecl in writin~ ancl
approved by the CIty. Nothiag hereia shall preclucle Consultant from proHicli~~ addit" I
C' . I f"' I ' . b lona
oernees a ~onsu tant s own cost and expense.
Categor/ofEmployce
Rate Seheclule4
1':ame of Consultant
Hourly Rate
S
$
$
$
$
( ) Hourly rates may increase by 6% for services renclerecl after [month] 20 'f cI I .
. .". .. ' , I e a)
III provluIllg servIces IS caused by City. -
11. Materials Reimbillsement }.!Tangement
F or the .cost of out of pocket expenses incurrecl by Coasultant in the performanee of services
herem reqmred, CIty shall pay Consultaat at the rates or amounts set forth below:
( ) None, the compensation inclucles all costs.
Cost or Rate
$
$
S
$
$
$
$
H Reports, not to exceed $
H Copies, not to e;:ceecl $
H Tra'lel, not to exceecl $
H Printing, not to exeeecl $
H Postage, not to exceecl $
H Delivery, not to exceed $
H Long Distanee Telephone Charges, not to e;cceed $
4. This section should be compliJted in all cases if tho main eompensatioa scheme is a "time
and matJnalG arrongoment" or for the purposes of reqHiring }.clditional Services.
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H Other ",.crual Identifiable Direct Costs:
, not to e::ceed S
, not to e::ceed S
$
S
S
12. Contract :\dministrators:
City:~
Constlltant:"
13. Liquidated Damages Rate:
( ) $
( ) Other:
por day.
11. Statement of Economic Interests ConsIolltant R rf .
,...,~~~. "cpo m~ Cate~efl G fl'
== " "es, per on let of Intef8st
E \ '" t ^ I'
J . ,0 . .pp ICMle. 1'Yot an FPPC Fi]er.+
( ) FPPC Filer
( ) Cate,;ory No. I. Inyestments and sources of'
mcome.
( ) Cate,;ory No.2. Intcrests in real proporty.
( ) Cate,;ory "Yo. 3. Inyostmants, intorost in real ro' .
to the ro,;ulatory pormit or lie . ~ . p pert) and sources of mcome subj cct
, ensm" atttl:onty ofthc departmcnt.
5. Sample Completion:
Marilyn Posog,;i, Environmental Renie'" Co d' .
276 FOtlfth ",.'{onue Chula "ista C: 9i9100r mator, Pubhc Seryiees Eui1dinc::
, " n ,(619) 6915101. -'
6. Same as address ctc. on E::h' 13 1 ],
. . " . ,p us name of lead conlact.
7. If Consultant, in the performance ofils ser" a '
a . ,Ieos un-or tms agfe I El'
an arn';()s atconcbsions ",ith respect to its rendilisfl sf' t< emen: ,conducts research
recommendatIOns or counsel indo end t f 1R ormatlOn, adnce,
City official, other than nonna1 coF'ntracetn 0 ~~e control and direction oftha City or of ann
. mom.onn " ana E'1\ .. J
respect to any CIty decision be' 'on~ tt.. ~. . '" . - J possesses no authonty with
J "He ren"ltJon ofmfu t' a .
counsel, Consultant should Rot be de' t d rma lOR, a VICe, recommendations or
sl,;na e as an FPPC filer.
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Page 21
( ) fa~~o~y fJo. ~. In':estments in basiness entities and somces of income that en~a~e in
an 0, e opment, constmetlOn or the acquisition or sale of real property. '" '"
( ) ~.atcgo~::.Na. 5. In':estmeffis in busincss entities and sources of income of the t e
Edn:h:. 'j Itlun the fast two years, have coooacted ':lith the City of Chula Vista yp
,o..e. e opment. .gency) to proVIde sen'ices, sapplies, matcrials machinery or
eqUIpment. ' .
( ) ~.~tc~O?:.l'~? Oh Ir.':estments in business entities and sources of income of the type
.. IC , .. It m t e past two years, have coooacted with the desimated em 10 .ee's
depail'H~nt to proYlde services supplies mat~rials h' '" . jl )
, , ,mac mery or eqUlpmont.
( ) Category No. 7. Business positions.
( ) List "Con~ultant .^.ssoeiatos" interests in roal property within'" r d' I '1 fP'
Property, If any: . - a 1a ml es 0 rOj eet
15. ( ) Consultant is Real Estate Broker and/or Salesman
10. Permitted Subconsultants:
17. Bill Processing:
.\. Consultant's Billing to b~ submitted for the following period aftime:
( ) Menthly
( ) Quarter! y
( ) Other:
B. Day of the Poried for submission ofConsultaffi's Billin~'
"'.
( ) First ofilie ~.ionth
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() 15th Day of each. Month
( ) End of the ~.fonth
( ) Other:
C. City's Acco,mt :--[umber:
18. Security for Performance
( X)Performance Bond, $
. Generally, a performance bond is customary for architects or builders who are in
the construction industry but not for a company selling insurance policies.
AFLAC does not purchase a performance bond because it is not applicable to our
busi ness.
. AFLAC is a fully-insured company that maintains a blanket fidelity bond through
the St. Paul Guardian Insurance Company in the amount of$20,000,000
aggregate policy limit. We also maintain commercial general liability,
automobile, statutory workers' compensation, and employer's liability coverage.
Coverage applies to employees of AFLAC Incorporated.
. Please see the attached Certificate of Insurance.
. AFLAC does not maintain Errors and Omissions (E&O) coverage as a company.
We feel our assets are sufficient to cover any losses resulting from E&O. Tessa
Goetz-Munster and any AFLAC agents will provide proof of E&O coverage to
the City.
( X)Letter of Credit, $ See Attaclunent B.
( ) Other Securi ty:
Type:
Amount: $
( ) Retention. If this space is ched~ed, then noty;ithstandin; other proyisions to the contrary
requiring the pa)IDent of compensation to the Consultant sooner, the City shall be entitled
to retain, at their option, either the f-olloy;in; "Retention Perccnta;~" or "Retention
/.m.ount" Matil tne City determiaes that the Retontion Release Event, listed belov:, has
occHcITed:
( ) R~tention Percentage:
( ) Retention ".mount: $
~~
Retention Release Event:
( ) Completion of .-\11 Consultant Senices
( ) Other:
RAttomey/2pty15
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