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PLAN SPONSOR DISCLOSURE STATEMENT (TIlt' /oilu'i-'mg will be treated as strictly conFLdential information by Slarulard Sccurily Life lnsurm;ce Company of New York ('(Standard Secumy"j Legal Name of Plan Sponsor: City of La Parte. IX In order for Standard Security to consider issuing a contract that waives the "Actively-at-work" provision, the Plan Sponsor and its named Agent/TPA must disclose the pertinent details regarding employees and their depel'1dents who meet certain crrteria. This needs to be reported on Active Employees and their dependents, Retired Employees and their dependents (if coveredL Disabled individuals, and/or Individuals on COBRA. By signing below you acknowledge that you understand wnat is expected of you and have completed your due diligence in researching this information. There are several categories of individuals who must be reported. They are as follows: Individuals who have reached 50% of the specific deductible. If an Individual has reached 50% cf the specific deductible based on the total of unprocessed, pending and/or paid claims they need to be reported in Section 1 of the Disclosure Statement. Individuals who are not actively at work or In the case 01 dependents, who are confined In the hospital, home, or elsewhere. These individuals should be listed in Section 2 of the Disclosure Statement. To effectively report these individuals, you must checx with your TPA, Broker, Human Resources department, Pre-certification Company and Large Case Management vendor regarding any open cases. Individuals who should be reported due to "trigger diagnosis". Individuals meeting this criteria should be reported in Section 3 of the Disclosure Statement. This should include employees or dependents with a HISTORY or CURRENT diagnosis of any serious disease or disorder, including BUT NOT LIMITED TO: cancer, diabetes, heart aisease, AIDS and AIDS Related Compiex (ARC), leukemia, muscular/neuro-diseases, high risk pregnancy, organ transplants, etc. For a more formal list please refer to the attached "Examples of Diagnoses of Potential High Dollar Claims" Disabled Individuals. Disabled individuals whether on temporary, short-term, or lang-term disability shOUld be reported in Section 4 of the Disclosure Statement. Plan Sponsor: City of La Porte, TX Printed Name: NO R-mCl Vi lv, meulon-e Title: t::~ Signatur.;t-,tt?'E!~ Date~_ D?- ~t:'- Proposed Effective Date of Stop Loss Policy: ~o~ TPA .c.,uthorized Agent Printed Name: /VEAL tv. W€LO/ Title: t/?e.SI den-t._ _____ Signatu~ Date: 3 I,i' /0'2- April 1 , 2002 SSL.I)SCL (12(99) Page 1 of 4 4 .