HomeMy WebLinkAbout8-17-06 Agenda PacketNOTICE OF EXECUTIVE AND
REGULAR SESSIONS OF THE
FOUNTAIN HILLS TOWN COUNCIL
Mayor Wally Nichols
Councilmember Mike Archambault Councilmember Henry Leger
Councilmember Ginny Dickey Councilmember Keith McMahan
Vice Mayor Ed Kehe Councilmember Jay Schlum
TIME: 5:15 P.M. to 6:30 P.M. - EXECUTIVE SESSION
(Executive Session will be held in 2nd floor Conference Room)
6:30 P.M. - REGULAR SESSION
WHEN: THURSDAY, AUGUST 17, 2006
WHERE: FOUNTAIN HILLS COUNCIL CHAMBERS
16705 E. AVENUE OF THE FOUNTAINS, FOUNTAIN HILLS, AZ
PROCEDURE FOR ADDRESSING THE COUNCIL
Anyone wishing to speak before the Council must fill out a speaker’s card and submit it to the
Town Clerk prior to Council discussion of that Agenda item. Speaker Cards are located in
the Council Chamber Lobby and near the Clerk’s position on the dais.
Speakers will be called in the order in which the speaker cards were received either by the Clerk
or the Mayor. At that time, speakers should stand and approach the podium. Speakers are
asked to state their name prior to commenting and to direct their comments to the Presiding
Officer and not to individual Councilmembers. Speakers’ statements should not be
repetitive. If a speaker chooses not to speak when called, the speaker will be deemed to
have waived his or her opportunity to speak on the matter. Speakers may not (i) reserve a
portion of their time for a later time or (ii) transfer any portion of their time to another
speaker.
If there is a Public Hearing, please submit the speaker card to speak to that issue during
the Public Hearing.
Individual speakers will be allowed three contiguous minutes to address the Council. Time
limits may be waived by (i) discretion of the Town Manager upon request by the speaker not
less than 24 hours prior to a Meeting, (ii) consensus of the Council at Meeting or (iii) the
Mayor either prior to or during a Meeting. Please be respectful when making your
comments. If you do not comply with these rules, you will be asked to leave.
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• CALL TO ORDER –Mayor Nichols
1. ROLL CALL AND VOTE TO GO INTO EXECUTIVE SESSION: Pursuant to A.R.S.
§38-431-03.A.1, For discussion or consideration of employment, assignment, appointment,
promotion, demotion, dismissal, salaries, disciplining or resignation of a public officer,
appointee or employee of any public body, except that, with the exception of salary
discussions, an officer, appointee or employee may demand that the discussion or
consideration occur at a public meeting. The public body shall provide the officer, appointee
or employee with written notice of the executive session as is appropriate but not less than
twenty-four hours for the officer, appointee or employee to determine whether the discussion
or consideration should occur at a public meeting. (Specifically, to conduct interviews of
qualified candidates who applied for vacancies on the Planning and Zoning Commission.)
2. RETURN TO REGULAR SESSION
• CALL TO ORDER AND PLEDGE OF ALLEGIANCE – Mayor Nichols
• INVOCATION – Pastor David Felten, Fountains Methodist Church
• ROLL CALL – Mayor Nichols
• SCHEDULED PUBLIC APPEARANCES/PRESENTATIONS - UPDATE by the
Strategic Planning Advisory Commission (SPAC) on implementation of the Town’s
Strategic Plan. Resident Curt Dunham, SPAC Chairman, will give the Council an
overview of the SPAC's activities and accomplishments and the status of the strategic
plan implementation.
CALL TO THE PUBLIC
Pursuant to A.R.S. §38-431-01(G), public comment is permitted (not required) on matters not listed
on the agenda. Any such comment (i) must be within the jurisdiction of the Council and (ii) is
subject to reasonable time, place, and manner restrictions. The Council will not discuss or take
legal action on matters raised during “Call to the Public” unless the matters are properly noticed for
discussion and legal action. At the conclusion of the call to the public, individual Councilmembers
may (i) respond to criticism, (ii) ask staff to review a matter or (iii) ask that the matter be placed on
a future Council agenda.
CONSENT AGENDA
1.) CONSIDERATION of approving the TOWN COUNCIL MEETING MINUTES from
August 3, 2006.
2.) CONSIDERATION of RESOLUTION 2006-45, approving an Intergovernmental
Agreement with the Office of the State Fire Marshal, to conduct certain inspections and
related activities according to statutory requirements.
3.) CONSIDERATION of extending the approval of the Preliminary Plat for “High Nob Acres,”
a proposed 11 lot single-family residential subdivision located on Lot 34 of Block 1, Final
Plat 506-C and the abutting unplatted parcel of land to the west of Lot 34; Case No. S2004-
22.
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4.) CONSIDERATION of RESOLUTION 2006-44, which rescinds Resolution 1999-62 (a
previous Alley abandonment, with unfilled stipulations).
5.) CONSIDERATION of approving a one-year renewal with Markham Contracting Company
for the annual asphalt and concrete concrete.
6.) CONSIDERATION of approving Ameritas Life Insurance Corp. as the dental insurance
carrier and Fort Dearborn Life Insurance Co. as the life insurance carrier for the Town of
Fountain Hills employees in 2006-07.
7.) CONSIDERATION of RESOLUTION 2006-38, approving an INTERGOVERNMENTAL
AGREEMENT between the Town of Fountain Hills and Maricopa County for operating and
administering a Special Transportation Service for the period staring on July 1, 2006 and
ending on June 30, 2007, in the amount of $42,571.50.
8.) CONSIDERATION of a REPLAT of lot 2 in “Sheridan Plaza”, located at 13125 La
Montana Drive, into two lots. Case# S2006-16.
9.) CONSIDERATION of a Lot-Join REPLAT for “Pal’s Inn Pet Resort,” located at 11669
Saguaro Blvd., aka Plat 302, Block 1, Lots 3 and 4. Case #S2006-12.
10.) CONSIDERATION of approving the donation of an art piece for public display by the local
Veterans at the Veterans Memorial.
11.) CONSIDERATION of approving a purchase agreement with Five Star Ford for a full size
Ford pick-up in the amount of $25,402.77.
12.) CONSIDERATION of approving a liquor license APPLICATION for Ronald Schmitt
(Bruno’s Sports Bar and Grille, LLC) located at 16737 E. Parkview Ave., Fountain Hills, AZ.
This request is for a series #6 license.
REGULAR AGENDA
13.) CONSIDERATION of approving the release of funds to Fountain Hills Chamber of
Commerce Tourism Bureau in the amount of $125,000.
14.) PUBLIC HEARING of a SPECIAL USE PERMIT to allow “Pal’s Inn,” a pet resort project
located at 11669 N. Saguaro Boulevard, to provide kenneling, an outdoor exercise area, and
extended hours of operation. Case Number SU2006-01.
15.) CONSIDERATION of a SPECIAL USE PERMIT to allow “Pal’s Inn,” a pet resort project
located at 11669 N. Saguaro Boulevard to provide kenneling, an outdoor exercise area, and
extended hours of operation. Case Number SU2006-01.
16.) PUBLIC HEARING of ORDINANCE #06-21, an amendment to Chapter 10 - Health and
Sanitation, of the Town Code. If adopted the ordinance would ensure that swimming pools
and similar water features are continuously maintained in a healthy and blight-free condition.
17.) CONSIDERATION of ORDINANCE #06-21, an amendment to Chapter 10 - Health and
Sanitation, of the Town Code. If adopted the ordinance would ensure that swimming pools
and similar water features are continuously maintained in a healthy and blight-free condition.
18.) CONSIDERATION of Awarding a Contract for construction of the Desert Vista Skate Park
to Concast Corporation in the amount of $326,702.
19.) SUMMARY of COUNCIL REQUESTS by Town Manager.
20.) ADJOURNMENT.
DATED this 15th day of August 2006.
Bevelyn J. Bender, Town Clerk
The Town of Fountain Hills endeavors to make all public meetings accessible to persons with disabilities. Please call 837-2003
(voice) or 1-800-367-8939 (TDD) 48 hours prior to the meeting to request a reasonable accommodation to participate in this meeting
or to obtain agenda information in large print format. Supporting documentation and staff reports furnished the Council with this
agenda are available for review in the Clerk’s office.
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669195.1
RESOLUTION NO. 2006-44
A RESOLUTION OF THE MAYOR AND COUNCIL OF THE TOWN OF
FOUNTAIN HILLS, ARIZONA, REPEALING RESOLUTION NO. 1999-62
RELATING TO THE ABANDONMENT OF CERTAIN REAL PROPERTY
GENERALLY LOCATED ADJACENT TO DESERT VISTA NEIGHBORHOOD
PARK BETWEEN DESERT VISTA DRIVE AND TOWER DRIVE.
WHEREAS, the Mayor and Council of the Town of Fountain Hills, Arizona (the “Town
Council”) passed and adopted Resolution No. 1999-62 on December 16, 1999 (the “Resolution”)
abandoning all right title and interest in a certain portion of public right-of-way generally located
adjacent to Desert Vista Neighborhood Park between Desert Vista Drive and Tower Drive (the
“Right-of-Way”); and
WHEREAS, the Town Council (i) has determined that the stipulations imposed upon the
abandonment of the Right-of-Way have not been met and (ii) desires to rescind the Resolution as
requested by the owners of record of the real property south of the Right-of-Way.
NOW THEREFORE, BE IT RESOLVED, BY THE MAYOR AND COUNCIL OF
THE TOWN OF FOUNTAIN HILLS, ARIZONA, as follows:
SECTION 1. That Resolution No. 1999-62 is hereby repealed.
SECTION 2. That upon recordation of this Resolution in the office of the Maricopa
County Recorder, title to the Right-of-Way, as more particularly described and depicted in
Exhibit A, attached hereto and incorporated herein by reference, shall vest in the Town of
Fountain Hills.
SECTION 3. That if any section, subsection, sentence, clause, phrase or portion of this
Resolution is for any reason to be held invalid or unconstitutional by the decision of any court of
competent jurisdiction, such decision shall not affect the validity of the remaining portions
thereof.
SECTION 4. That the Mayor, the Town Manager, the Town Clerk and the Town
Attorney are hereby authorized and directed to take all steps and to execute all documents
necessary to carry out the purpose and intent of this Resolution.
PASSED AND ADOPTED by the Mayor and Council of the Town of Fountain Hills,
Arizona, August 17, 2006.
FOR THE TOWN OF FOUNTAIN HILLS: ATTESTED TO:
W. J. Nichols, Mayor Bevelyn J. Bender, Town Clerk
669195.1
2
REVIEWED BY: APPROVED AS TO FORM:
Timothy G. Pickering, Town Manager Andrew J. McGuire, Town Attorney
669195.1
EXHIBIT A
TO
RESOLUTION 2006-44
[Legal description and map of the Right-of-Way]
See following pages.
669195.1
LEGAL DESCRIPTION OF RIGHT-OF-WAY
That portion of alley located northeast of an abutting Lots 3 through 5, Block 1, Plat 302,
Fountain Hills, Arizona as recorded in book 156 of Maps, page 45, and in book 516 of Maps,
page 43, respectively records of Maricopa County, Arizona.
9000 Ed. 01-05
A STOCK COMPANY
LINCOLN, NEBRASKA
GROUP DENTAL INSURANCE POLICY
The Policyholder TOWN OF FOUNTAIN HILLS
Policy Number 10-999998
State of Delivery Arizona Plan Effective Date September 1, 2006
Premium Due Date 1st of each month. Renewal Date September 1, 2007
Ameritas Life Insurance Corp. agrees to pay, with respect to each Insured Person, the group insurance benefits
provided in this policy.
This policy is issued to the Policyholder in consideration of the Policyholder's application and the payment of
premiums, as provided herein.
This policy is delivered in and governed by the laws of the state of delivery.
AMERITAS LIFE INSURANCE CORP.
Secretary President
Specimen
AZ-Appeals Ed. 01-05
Health Care Insurer Appeals Process Information Packet
CAREFULLY READ THE INFORMATION IN THIS PACKET AND KEEP IT FOR FUTURE
REFERENCE. IT HAS IMPORTANT INFORMATION ABOUT HOW TO APPEAL DECISIONS WE
MAKE ABOUT YOUR HEALTH CARE.
Getting Information About the Health Care Appeals Process
Help in Filing an Appeal: Standardized Forms and Consumer Assistance From
the Department of Insurance
We must send you a copy of this information packet when you first receive your policy, and within 5 business
days after we receive your request for an appeal. When your insurance coverage is renewed, we must also send
you a separate statement to remind you that you can request another copy of this packet. We will also send a copy
of this packet to you or your treating provider at any time upon request. Just call our customer/member services
number at 800-547-9515 to ask.
At the back of this packet, you will find a form that you can use for your appeal. The Arizona Insurance
Department (“the Department”) developed this form to help people who want to file a health care appeal. You are
not required to use it. We cannot reject your appeal if you do not use the form. If you need help in filing an
appeal, or you have questions about the appeals process, you may call the Department’s Consumer Assistance
Office at (602) 912-8444 or 1-(800) 325-2548 or call us at 800-366-5933.
How to Know When You Can Appeal
When we do not authorize or approve a service or pay for a claim, we must notify you of your right to appeal that
decision. Your notice may come directly from us, or through your treating provider.
Decisions You Can Appeal
You can appeal the following decisions:
1. We do not approve a service that you or your treating provider has requested.
2. We do not pay for a service that you have already received.
3. We do not authorize a service or pay for a claim because we say that it is not “medically necessary.”
4. We do not authorize a service or pay for a claim because we say that it is not covered under your
insurance policy, and you believe it is covered.
5. We do not notify you, within 10 business days of receiving your request, whether or not we will
authorize a requested service.
Decisions You Cannot Appeal
You cannot appeal the following decisions:
1. You disagree with our decision as to the amount of “usual and customary charges.”
2. You disagree with how we are coordinating benefits when you have health insurance with more than
one insurer.
3. You disagree with how we have applied your claims or services to your plan deductible.
4. You disagree with the amount of coinsurance or co-payments that you paid.
5. You disagree with our decision to issue or not issue a policy to you.
6. You are dissatisfied with any rate increases you may receive under your insurance policy.
7. You believe we have violated any other parts of the Arizona Insurance Code.
If you disagree with a decision that is not appealable according to this list, you may still file a complaint with the
Arizona Department of Insurance, Consumer Affairs Division, 2910 N. 44th, Second Floor, Phoenix, Arizona
85018.
Who Can File An Appeal ?
Either you or your treating provider can file an appeal on your behalf. At the end of this packet is a form that you
may use for filing your appeal. You are not required to use this form, and can send us a letter with the same
information. If you decide to appeal our decision to deny authorization for a service, you should tell your treating
provider so the provider can help you with the information you need to present your case.
Description of the Appeals Process
There are two types of appeals: an expedited appeal for urgent matters, and a standard appeal. Each type of
appeal has 3 levels. The appeals operate in a similar fashion, except that expedited appeals are processed much
faster because of the patient’s condition.
Expedited Appeals Standard Appeals
(for urgently needed services (for non-urgent services or denied claims)
you have not yet received)
Level 1 Expedited Medical Review Informal Reconsideration*
Level 2 Expedited Appeal Formal Appeal
Level 3 Expedited External Independent External Independent Medical
Medical Review Review
We make the decisions at Level 1 and Level 2. An outside reviewer, who is completely independent from our
company, makes Level 3 decisions. You are not responsible to pay the costs of the external review if you choose
to appeal to Level 3.
*Informal reconsideration is not available for a denied claim but will be available for pre-treatment estimates.
EXPEDITED APPEAL PROCESS FOR URGENTLY NEEDED SERVICES
NOT YET PROVIDED
Level 1: Expedited Medical Review
Your request:You may obtain Expedited Medical Review of your denied request for a service that has not
already been provided if:
•You have coverage with us,
•We denied your request for a covered service, and
•Your treating provider certifies in writing and provides supporting documentation that the time required to
process your request through the Informal Reconsideration and Formal Appeal (about 60 days) is likely to
cause a significant negative change in your medical condition. (At the end of this packet is a form that your
provider may use for this purpose. Your provider could also send a letter or make up a form with similar
information.) Your treating provider must send the certification and documentation to:
Name: Quality Control Phone: 800-366-5933
Address: P.O. Box 82657 Fax: 402-309-2580
Lincoln, NE 68501-2657
Our decision:We have 1 business day after we receive the information from the treating provider to decide
whether we should change our decision and authorize your requested service. Within that same business day, we
must call and tell you and your treating provider, and mail you our decision in writing. The written decision must
explain the reasons for our decision and tell you the documents on which we based our decision.
If we deny your request:You may immediately appeal to Level 2.
If we grant your request:We will authorize the service and the appeal is over.
If we refer your case to Level 3:We may decide to skip Level 1 and Level 2 and send your case
straight to an independent reviewer at Level 3.
Level 2: Expedited Appeal
Your request:If we deny your request at Level 1, you may request an Expedited Appeal. After you receive our
Level 1 denial, your treating provider must immediately send us a written request (to the same person and address
listed above under Level 1) to tell us you are appealing to Level 2. To help your appeal, your provider should
also send us any more information (that the provider hasn’t already sent us) to show why you need the requested
service.
Our decision:We have 3 business days after we receive the request to make our decision.
If we deny your request:You may immediately appeal to Level 3.
If we grant your request:We will authorize the service and the appeal is over.
If we refer your case to Level 3:We may decide to skip Level 2 and send your case straight to an
independent reviewer at Level 3.
Level 3: Expedited External, Independent Review
Your request: You may appeal to Level 3 only after you have appealed through Levels 1 and 2. You have only
5 business days after you receive our Level 2 decision to send us your written request for Expedited External
Independent Review. Send your request and any more supporting information to:
Name: Quality Control Phone: 800-366-5933
Address: P.O. Box 82657 Fax: 402-309-2580
Lincoln, NE 68501-2657
Neither you nor your treating provider is responsible for the cost of any external independent review.
The process:There are two types of Level 3 appeals, depending on the issues in your case:
(1) Medical necessity
These are cases where we have decided not to authorize a service because we think the services you (or
your treating provider) are asking for, are not medically necessary to treat your problem. For medical
necessity cases, the independent reviewer is a provider retained by an outside independent review
organization (“IRO”), that is procured by the Arizona Insurance Department, and not connected with our
company. The IRO provider must be a provider who typically manages the condition under review.
(2) Contract coverage
These are cases where we have denied coverage because we believe the requested service is not covered
under your insurance policy. For contract coverage cases, the Arizona Insurance Department is the
independent reviewer.
Medical Necessity Cases
Within 1 business day of receiving your request, we must:
1. Mail a written acknowledgment of the request to the Director of Insurance, you, and your treating
provider.
2. Send the Director of Insurance: the request for review; your policy, evidence of coverage or similar
document; all medical records and supporting documentation used to render our decision; a summary
of the applicable issues including a statement of our decision; the criteria used and clinical reasons for
our decision; and the relevant portions of our utilization review guidelines. We must also include the
name and credentials of the health care provider who reviewed and upheld the denial at the earlier
appeal levels.
Within 2 business days of receiving our information, the Insurance Director must send all the submitted
information to an external independent reviewer organization (the “IRO”).
Within 5 business days of receiving the information the IRO must make a decision and send the decision to the
Insurance Director.
Within 1 business day of receiving the IRO’s decision, the Insurance Director must mail a notice of the decision
to us, you, and your treating provider.
The decision (medical necessity):If the IRO decides that we should provide the service, we must authorize
the service. If the IRO agrees with our decision to deny the service, the appeal is over. Your only further option
is to pursue your claim in Superior Court.
Contract Coverage Cases
Within 1 business day of receiving your request, we must:
1. Mail a written acknowledgment of your request to the Insurance Director, you, and your treating
provider.
2. Send the Director of Insurance: the review, your policy, evidence of coverage or similar document, all
medical records and supporting documentation used to render our decision, a summary of the
applicable issues including a statement of our decision, the criteria used and any clinical reasons for
our decision and the relevant portions of our utilization review guidelines.
Within 2 business days of receiving this information, the Insurance Director must determine if the service or
claim is covered, issue a decision, and send a notice to us, you, and your treating provider.
Referral to the IRO for contract coverage cases:The Insurance Director is sometimes unable to determine issues
of coverage. If this occurs, the Insurance Director will forward your case to an IRO. The IRO will have 5
business days to make a decision and send it to the Insurance Director. The Insurance Director will have 1
business day after receiving the IRO’s decision to send the decision to us, you, and your treating provider.
The decision (contract coverage):If you disagree with Insurance Director’s final decision on a contract
coverage issue, you may request a hearing with the Office of Administrative Hearings (“OAH”). If we disagree
with the Director’s final decision, we may also request a hearing before OAH. A hearing must be requested
within 30 days of receiving the Director’s decision. OAH must promptly schedule and complete a hearing for
appeals from expedited Level 3 decisions.
STANDARD APPEAL PROCESS FOR NON-URGENT SERVICES AND DENIED CLAIMS
Level 1. Informal Reconsideration
Your request:You may obtain Informal Reconsideration of your denied request for a service if:
•You have coverage with us,
•We denied your request for a covered service,
•You do not qualify for an expedited appeal, and
•You or your treating provider asks for Informal Reconsideration within 2 years of the date we first deny the
requested service by calling, writing, or faxing your request to:
Name: Quality Control Phone: 800-366-5933
Address: P.O. Box 82657 Fax: 402-309-2580
Lincoln, NE 68501-2657
Claim for a covered service already provided but not paid for:You may not obtain Informal Reconsideration
of your denied request for the payment of a covered service. Instead, you may start the review process by seeking
Formal Appeal.
Our acknowledgment:We have 5 business days after we receive your request for Informal Reconsideration
(“the receipt date”) to send you and your treating provider a notice that we got your request.
Our decision:We have 30 days after the receipt date to decide whether we should change our decision and
authorize your requested service. Within the same 30 days, we must send you and your treating provider our
written decision. The written decision must explain the reasons for our decision and tell you the documents on
which we based our decision.
If we deny your request:Youhave60daystoappealtoLevel2.
If we grant your request:The decision will authorize the service and the appeal is over.
If we refer your case to Level 3:We may decide to skip Level 1 and Level 2 and send your case
straight to an independent reviewer at Level 3.
Level 2. Formal Appeal
Your request:You may request Formal Appeal if: (1) we deny your request at Level 1, or (2) you have an
unpaid claim and we did not provide a Level 1 review. After you receive our Level 1 denial, you or your treating
provider must send us a written request within 60 days to tell us you are appealing to Level 2. If we did not
provide a Level 1 review of your denied claim, you have 2 years from our first denial notice to request Formal
Appeal. To help us make a decision on your appeal, you or your provider should also send us any more
information (that you haven’t already sent us) to show why we should authorize the requested service or pay the
claim. Send your appeal request and information to:
Name: Quality Control Phone: 800-366-5933
Address: P.O. Box 82657 Fax: 402-309-2580
Lincoln, NE 68501-2657
Our acknowledgment:We have 5 business days after we receive your request for Formal Appeal (“the receipt
date”) to send you and your treating provider a notice that we got your request.
Our decision:For a denied service that you have not received, we have 30 days after the receipt date to decide
whether we should change our decision and authorized your requested service. For denied claims, we have 60
days to decide whether we should change our decision and pay your claim. We will send you and your treating
provider our decision in writing. The written decision must explain the reasons for our decision and tell you the
documents on which we based our decision.
If we deny your request or claim:Youhave30daystoappealtoLevel3.
If we grant your request:We will authorize the service or pay the claim and the appeal is over.
If we refer your case to Level 3:We may decide to skip Level 2 and send your case straight to an
independent reviewer at Level 3.
Level 3: External, Independent Review
Your request:You may appeal to Level 3 only after you have appealed through Levels 1 and 2. You have 30
days after you receive our Level 2 decision to send us your written request for External Independent Review.
Send your request and any more supporting information to:
Name: Quality Control Phone: 800-366-5933
Address: P.O. Box 82657 Fax: 402-309-2580
Lincoln, NE 68501-2657
Neither you nor your treating provider is responsible for the cost of any external independent review.
The process:There are two types of Level 3 appeals, depending on the issues in your case:
(1) Medical necessity
These are cases where we have decided not to pay a claim because we think the services that were
provided, were not medically necessary to treat your problem. For medical necessity cases, the
independent reviewer is a provider retained by an outside independent review organization (IRO),
procured by the Arizona Insurance Department, and not connected with our company. For medical
necessity cases, the provider must be a provider who typically manages the condition under review.
(2) Contract Coverage
These are cases where we have denied coverage because we believe the requested service is not covered
under your insurance policy. For contract coverage cases, the Arizona Insurance Department is the
independent reviewer.
Medical Necessity Cases
Within 5 business days of receiving your request, we must:
1. Mail a written acknowledgment of the request to the Director of Insurance, you, and your treating
provider.
2. Send the Director of Insurance: the request for review; your policy, evidence of coverage or similar
document; all medical records and supporting documentation used to render our decision; a summary
of the applicable issues including a statement of our decision; the criteria used and clinical reasons for
our decision; and the relevant portions of our utilization review guidelines. We must also include the
name and credentials of the health care provider who reviewed and upheld the denial at the earlier
appeal levels.
Within 5 days of receiving our information, the Insurance Director must send all the submitted information to an
external independent review organization (the “IRO”).
Within 21 days of receiving the information the IRO must make a decision and send the decision to the Insurance
Director.
Within 5 business days of receiving the IRO’s decision, the Insurance Director must mail a notice of the decision
to us, you, and your treating provider.
The decision (medical necessity):If the IRO decides that we should provide the service or pay the claim,
we must authorize the service or pay the claim. If the IRO agrees with our decision to deny the service or
payment, the appeal is over. Your only further option is to pursue your claim in Superior Court.
Contract Coverage Cases
Within 5 business days of receiving your request, we must:
1. Mail a written acknowledgment of your request to the Insurance Director, you, and your treating
provider.
2. Send the Director of Insurance: the request for review; your policy, evidence of coverage or similar
document; all medical records and supporting documentation used to render our decision; a summary
of the applicable issues including a statement of our decision; the criteria used and any clinical reasons
for our decision; and the relevant portions of our utilization review guidelines.
Within 15 business days of receiving this information, the Insurance Director must determine if the service or
claim is covered, issue a decision, and send a notice to us,you, and your treating provider. If the Director decides
that we should provide the service or pay the claim, we must do so.
Referral to the IRO for contract coverage cases:The Insurance Director is sometimes unable to determine issues
of coverage. If this occurs, the Insurance Director will forward your case to an IRO. The IRO will have 21 days
to make a decision and send it to the Insurance Director. The Insurance Director will have 5 business days after
receiving the IRO’s decision to send the decision to us, you, and your treating provider.
The decision (contract coverage):If you disagree with the Insurance Director’s final decision on a coverage
issue, you may request a hearing with the Office of Administrative Hearings(“OAH”). If we disagree with the
Director’s determination of coverage issues, we may also request a hearing at OAH. Hearings must be requested
within 30 days of receiving the coverage issue determination. OAH has rules that govern the conduct of their
hearing proceedings.
Obtaining Medical Records
Arizona law (A.R.S. §12-2293) permits you to ask for a copy of your medical records. Your request must be in
writing and must specify who you want to receive the records. The health care provider who has your records
will provide you or the person you specified with a copy of your records.
Designated Decision-Maker:If you have a designated health care decision-maker, that person must send a
written request for access to or copies of your medical records. The medical records must be provided to your
health care decision-maker or a person designated in writing by your health care decision-make unless you limit
access to your medical records only to yourself or your health care decision-maker.
Confidentiality:Medical records disclosed under A.R.S. §12-2293 remain confidential. If you participate
in the appeal process, the relevant portions of your medical records may be disclosed only to people authorized to
participate in the review process for the medical condition under review. These people may not disclose your
medical information to any other people.
Documentation for an Appeal
If you decide to file an appeal, you must give us any material justification or documentation for the appeal at the
time the appeal is filed. If you gather new information during the course of your appeal, you should give it to us
as soon as you get it. You must also give us the address and phone number where you can be contacted. If the
appeal is already at Level 3, you should also send the information to the Department.
The Role of the Director of Insurance
Arizona law (A.R.S. §20-2533(F)) requires “any member who files a complaint with the Department relating to
an adverse decision to pursue the review process prescribed” by law. This means, that for appealable decisions,
you must pursue the health care appeals process before the Insurance Director can investigate a complaint you
may have against our company based on the decision at issue in the appeal.
The appeal process requires the Director to:
1. Oversee the appeals process.
2. Maintain copies of each utilization review plan submitted by insurers.
3. Receive, process, and act on requests from an insurer for External, Independent Review.
4. Enforce the decisions of insurers.
5. Review decisions of insurers.
6. Report to the Legislature.
7. Send, when necessary, a record of the proceedings of an appeal to Superior Court or to the Office of
Administrative Hearings (OAH).
8. Issue a final administrative decision on coverage issues, including the notice of the right to request a
hearing at OAH.
Receipt of Documents
Any written notice, acknowledgment, request, decision or other written document required to be mailed is deemed
received by the person to whom the document is properly addressed on the fifth business day after being mailed.
“Properly addressed” means your last known address.
Quality Control
P.O. Box 82657
Lincoln, NE 68501-2657
HEALTH CARE APPEAL REQUEST FORM
You may use this form to tell your insurer you want to appeal a denial decision.
Insured Member’s Name Member ID # _______________________
Name of representative pursuing appeal, if different from above _______________________________________
Mailing Address Phone # ___________________________
City _______________________ State __________________ Zip Code __________________________
Type of Denial: Denied Claim Denied Service Not Yet Received
Name of Insurer that denied the claim/service: ______________________________________________________
If you are appealing your insurer’s decision to deny a service you have not yet received, will a 30 to 60 day delay
in receiving the service likely cause a significant negative change in your health? If your answer is “Yes,” you
may be entitled to an expedited appeal. Your treating provider must sign and send a certification and
documentation supporting the need for an expedited appeal.
What decision are you appealing? _______________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
(Explain what you want your insurer to pay for).
Explain why you believe the claim or service should be covered:
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
(Attach additional sheets of paper, if needed).
If you have questions about the appeals process or need help to prepare your appeal, you may call the Department
of Insurance Consumer Assistance number (602) 912-8444 or 1-(800) 325-2548, or
Quality Control at 1-800-366-5933.
Make sure to attach everything that shows why you believe your insurer should cover your claim or
authorize a service, including:Medical records Supporting documentation (letter from your doctor,
brochures, notes, receipts, etc.) ** Also attach the certification from your treating provider if you are seeking
expedited review
_______________________________________________ ________________________________
Signature of insured or authorized representative Date
Quality Control
P.O. Box 82657
Lincoln, NE 68501-2657
PROVIDER CERTIFICATION FORM
FOR EXPEDITED MEDICAL REVIEWS
(You and your provider may use this form when requesting an expedited appeal.)
A patient who is denied authorization for a covered service is entitled to an expedited appeal if the treating
provider certifies and provides supporting documentation that the time period for the standard appeal
process (about 60 days) “is likely to cause a significant negative change in the [patient’s] medical condition
at issue.”
PROVIDER INFORMATION
Treating Physician/Provider ____________________________________________________________________
Phone # _______________________________ Fax # _________________________________
Address ___________________________________________________________________________________
City _______________________________ State ________________ Zip Code __________
PATIENT INFORMATION
Patient's Name __________________________________ Member ID # ____________________
Phone # _______________________________________
Address ___________________________________________________________________________________
City _______________________________ State ________________ Zip Code __________
INSURER INFORMATION
Insurer Name _______________________________________________________________________________
Phone # _______________________________________ Fax # _________________________________
Address ___________________________________________________________________________________
City _______________________________ State ________________ Zip Code __________
•Is the appeal for a service that the patient has already received? Yes No
If “Yes” the patient must pursue the standard appeals process and cannot use the expedited appeals process.
If “No”, continue with this form.
•What service denial is the patient appealing? _________________________________________________
_____________________________________________________________________________________
•Explain why you believe the patient needs the requested service and why the time for the standard appeal
process will harm the patient. _____________________________________________________________
____________________________________________________________________________________
Attach additional sheets if needed, and include:Medical records Supporting documentation
If you have questions about the appeals process or need help to prepare your appeal, you may call the Department
of Insurance Consumer Assistance number (602) 912-8444 or 1-(800) 325-2548, or Quality Control at 1-800-
366-5933.
I certify, as the patient’s treating provider, that delaying the patient’s care for the time period needed for the
informal reconsideration and formal appeal processes (about 60 days) is likely to cause a significant negative
change in the patient’s medical condition at issue.
Provider’s Signature Date ___________________________
9035 Ed. 01-05
TABLE OF CONTENTS
Name of Provision Page Number
Schedule of Benefits Begins on 9040
Benefit Information, including Deductibles, Coinsurance, & Maximums
Increased Maximum Benefit 9042
Premiums 9050
Definitions
Late Entrant, Dependent 9060
Conditions for Insurance 9070
Eligibility
Eligibility Period
Elimination Period
Contribution Requirement
Effective Date
Termination Date
Dental Expense Benefits 9219
Alternate Benefit provision
Limitations, including Elimination Periods,
Missing Tooth Clause, Cosmetic Clause, Late Entrant
Table of Dental Procedures 9232
Covered Procedures, Frequencies, Criteria
Orthodontic Expense Benefits 9260
Coordination of Benefits 9300
General Provisions 9310
Claim Forms
Proof of Loss
Payment of Benefits
General Provisions Continued 9323
Participation Requirements
Termination of Policy
Grace Period
9040 Ed. 01-05
SCHEDULE OF BENEFITS
OUTLINE OF COVERAGE
The Insurance for each Insured and each Insured Dependent will be based on the Insured's class shown in this
Schedule of Benefits.
Benefit Class Class Description
Class 1 Eligible Employees
DENTAL EXPENSE BENEFITS
When you select a Participating Provider, a discounted fee schedule is used which is intended to provide you, the
Insured, reduced out of pocket costs.
Deductible Amount:
When a Participating Provider is used:
Type 1, Type 2, and Type 3 Procedures $0
When a Non-Participating Provider is used:
Type 1 Procedures $0
Combined Type 2 and Type 3 Procedures - Each Benefit Period $25
Maximum Deductible per Benefit Period $25
Any deductible satisfied during the Benefit Period will be applied to both the Participating Provider Deductible
and the Non-Participating Provider Deductible. Once the Maximum Deductible per Benefit Period has been met,
no further deductible will be required.
On the date that three members of one family have satisfied their own Deductible Amounts for that Benefit
Period, no Covered Expenses incurred after that date by any other family member will be applied toward the
satisfaction of any Deductible Amount for the rest of that Benefit Period. No Covered Expense that was incurred
prior to such date, which was used to satisfy any part of a Deductible Amount, will be eligible for reimbursement.
Dental expenses incurred by an individual on or after January 1, 2006, but before September 1, 2006, will apply to
the Deductible Amount if:
a. proof is furnished to us that such dental expenses were applicable to the deductible under the
Policyholder's dental insurance policy in force immediately prior to September 1, 2006; and
b. such expenses would have been considered Covered Expenses under this policy had this policy been
in force at the time the expenses were incurred.
Participating Provider Non-Participating Provider
Coinsurance Percentage:
Type 1 Procedures 100% 100%
Type 2 Procedures 90%90%
Type 3 Procedures 60% 60%
When a Non-Participating Provider is used:
Maximum Amount - Each Benefit Period $2,000
When a Participating Provider is used:
Maximum Amount - Each Benefit Period $2,000
ORTHODONTIC EXPENSE BENEFITS
Deductible Amount - Once per lifetime $0
Coinsurance Percentage 50%
Maximum Benefit During Lifetime $1,500
The Maximum Benefit shown above will be modified for:
a. any person who was insured for an Orthodontic Expense Benefit under the prior carrier on August
31, 2006, and
b. on September 1, 2006 is both:
i. insured under the policy, and
ii. currently undergoing a Treatment Program which would have been a covered Treatment
Program under the prior carrier had the prior carrier's coverage remained in force.
The modification will result in a reduction of the Maximum Benefit based on:
a. the normal benefit payable under the policy for the current Treatment Program, minus
b. any amounts to which the person is entitled from the prior carrier for such Treatment Program.
Nothing stated above, however, will act to provide coverage or increase benefits, when the Treatment Program is
subject to any limitation shown on 9260.
You and/or your dependents must be insured under the dental plan for 12 months to be eligible for Orthodontic
Procedures. Please refer to the ORTHODONTIC EXPENSE BENEFITS page for details regarding
elimination period(s), limitations and exclusions.
9042 Rev. 02-05
INCREASED DENTAL MAXIMUM BENEFIT
Carry Over Amount Per Insured Person – Each Benefit Period $400
Benefit Threshold Per Insured Person – Each Benefit Period $750
Maximum Carry Over Amount $1,200
After the first Benefit Period following the coverage effective date, the Maximum Amount for Dental Expenses
Per Insured Person as shown in the Schedule of Benefits may be increased by the Carry Over Amount if:
a) The Insured Person has submitted a claim for dental expenses incurred during the preceding Benefit
Period; and
b) The benefits paid for dental expenses incurred in the preceding Benefit Period did not exceed the
Benefit Threshold.
In each succeeding Benefit Period in which the total dental expense benefits paid do not exceed the Benefit
Threshold, the Insured Person will be eligible for the Carry Over Amount.
The Carry Over Amount can be accumulated from one Benefit Period to the next up to the Maximum Carry Over
amount unless:
a) During any Benefit Period, dental expense benefits are paid in excess of the Threshold. In this
instance, there will be no additional Carry Over Amount for that Benefit Period; or
b) During any Benefit Period, no claims for dental expenses incurred during the preceding Benefit
Period are submitted. In this instance, there will be no Carry Over Amount for that Benefit Period,
and any accumulated Carry Over Amounts from previous Benefit Periods will be forfeited.
Eligibility for the Carry Over Amount will be established or reestablished at the time the first claim in a Benefit
Period is received for dental expenses incurred during that Benefit Period.
In order to properly calculate the Carry Over Amount, claims should be submitted timely in accordance with the
Proof of Loss provision found within the General Provisions. You have the right to request review of prior Carry
Over Amount calculations. The request for review must be within 24 months from the date the Carry Over
Amount was established.
9050 Ed. 01-05
PREMIUMS
TABLE OF MONTHLY PREMIUM RATES
PAYMENT OF PREMIUMS.The first premium will be due on the Policy Effective Date to cover the period
from that date to the first Premium Due Date. Other premiums will be due on or before each Premium Due Date.
Premiums are payable at our Home Office or at some other location to which we and the Policyholder agree.
PREMIUM DUE DATE.The Premium Due Date will be the first day of the month that falls on or after the
Policy Effective Date. If we agree with the Policyholder to the payment of premiums on a basis other than
monthly, the Premium Due Date will be fixed to match the correct basis. If there is a change in the method of
payment or Premium Due Date, a pro-rata charge in the premium due will be made.
PREMIUM STATEMENTS.The premium due as of any Premium Due Date is the number of units in force on
such date for each type of insurance multiplied by the rate shown in the Table of Premium Rates. A premium
statement will be made as of the Premium Due Date showing the premium payable. If premiums are payable on
other than a monthly basis, each statement will show any pro-rata premium charges and credits in the last
premium period due to changes in the number of Insureds and in the amount of insurance for which people are
insured. This is subject to the rules below.
SIMPLIFIED ACCOUNTING.The premium will start on the Premium Due Date falling on or after the date
the insurance or the increase in the insurance is effective for: a) a person becoming insured; or b) an increase in
the amount of insurance on any person. The premium will stop on the Premium Due Date falling on or after the
date of termination of insurance or through the date of service of the last paid claim. There will be no pro-rata
charges or credits for a partial month. If premiums are payable other than monthly, charges and credits will be
figured as though the Premium Due Date is monthly.
We will be liable for the return of unearned premiums to the Policyholder only for the 3 months before the date
we receive evidence that a return is due.
ADJUSTMENTS IN PREMIUM RATES.We may change the rates shown in the Table of Premium Rates by
giving the Policyholder at least 30 days advance written notice. We may change the rates at any time the
Schedule of Benefits, or any other terms and conditions of the policy, are changed. We will not change the rates
until the Renewal Date shown on the policy cover or more than once in any 12 month period thereafter, unless
there is a change in the Schedule of Benefits or a change in any other terms and conditions in the policy.
Notwithstanding the above, the Company reserves the right to change any one or more of the rates prior to the
Renewal Date or more than once in any 12 month period thereafter upon the occurrence of one or both of the
following:
1. We determine that the average number of dependent children for each Insured with Dependent coverage
exceeds 4.0; and/or
2. We determine that the number of Insureds is less than 80% of the number of Insureds covered under the
Policy as of either (i) the Plan Effective Date, if during the period of time between the Plan Effective Date
and the Renewal Date, or (ii) the most recent 12 month anniversary of the Renewal Date.
Should either or both of the above occur and should we elect to change rates as a result, we agree to notify the
Policyholder of the corresponding rate changes at least 30 days in advance of the Premium Due Date for which
the rate change shall be effective. The right to change rates as well as the timing of such changes in the above two
limited situations shall at all times be subject to applicable state laws and regulations.
RENEWAL DATE refers to the date each calendar year that the coverage issued under the group policy is
considered for renewal. The Renewal Date(s) are shown on the policy cover.
9060 Ed. 01-05
DEFINITIONS
COMPANY refers to Ameritas Life Insurance Corp. The words "we", "us" and "our" refer to Company. Our
Home Office address is 5900 "O" Street, Lincoln, Nebraska 68510.
POLICYHOLDER refers to the Policyholder stated on the face page of the policy.
INSURED refers to a person:
a. who is a Member of the eligible class; and
b. who has qualified for insurance by completing the eligibility period, if any; and
c. for whom the insurance has become effective.
CHILD. Child refers to the child of the Insured or a child of the Insured's spouse, if they otherwise meet the
definition of Dependent.
DEPENDENT refers to:
a. an Insured's spouse.
b. each unmarried child less than 19 years of age, for whom the Insured or the insured's spouse, is
legally responsible, including:
i. natural born children;
ii. adopted children, eligible from the date of placement for adoption;
iii. children covered under a Qualified Medical Child Support Order as defined by
applicable Federal and State laws.
c. each unmarried child age 19 but less than 24 who is:
i. a full time student at an accredited school or college, which includes a vocational,
technical, vocational-technical, trade school or institute; and
ii. primarily dependent on the Insured, the Insured's spouse for support and
maintenance.
d. each unmarried child age 19 or older who:
i. is Totally Disabled as defined below; and
ii. becomes Totally Disabled while insured as a dependent under b. or c. above.
Coverage of such child will not cease if proof of dependency and disability is given within 31
days of attaining the limiting age and subsequently as may be required by us but not more
frequently than annually after the initial two-year period following the child's attaining the
limiting age. Any costs for providing continuing proof will be at our expense.
TOTAL DISABILITY describes the Insured's Dependent as:
1. Continuously incapable of self-sustaining employment because of mental retardation or physical
handicap; and
2. Chiefly dependent upon the Insured for support and maintenance.
DEPENDENT UNIT refers to all of the people who are insured as the dependents of any one Insured.
PROVIDER refers to any person who is licensed by the law of the state in which treatment is provided within the
scope of the license.
LATE ENTRANT refers to any person:
a. whose Effective Date of insurance is more than 31 days from the date the person becomes eligible
for insurance; or
b. who has elected to become insured again after canceling a premium contribution agreement.
PLAN EFFECTIVE DATE refers to the date coverage under the policy becomes effective. The Plan Effective
Date for the Policyholder is shown on the policy cover. The effective date of coverage for an Insured is shown in
the Policyholder's records.
All insurance will begin at 12:01 A.M. on the Effective Date. It will end after 11:59 P.M. on the Termination
Date. All times are stated as Standard Time of the residence of the Insured.
PLAN CHANGE EFFECTIVE DATE refers to the date that the policy provisions originally issued to the
Policyholder change as requested by the Policyholder. The Plan Change Effective date for the Policyholder will
be shown on the policy cover, if the Policyholder has requested a change. The plan change effective date for an
Insured is shown in the Policyholder’s records or on the cover of the certificate.
9070 AZ Ed. 01-05
CONDITIONS FOR INSURANCE COVERAGE
ELIGIBILITY
ELIGIBLE CLASS FOR MEMBERS.The members of the eligible class(es) are shown on the Schedule of
Benefits. Each member of the eligible class (referred to as "Member") will qualify for such insurance on the day
he or she completes the required eligibility period, if any. Members choosing to elect coverage will hereinafter be
referred to as “Insured.”
If employment is the basis for membership, a member of the Eligible Class for Insurance is any eligible
employees working at least 30 hours per week. If membership is by reason other than employment, then a
member of the Eligible Class for Insurance is as defined by the Policyholder.
If a husband and wife are both Members and if either of them insures their dependent children, then the husband
or wife, whoever elects, will be considered the dependent of the other. As a dependent, the person will not be
considered a Member of the Eligible Class, but will be eligible for insurance as a dependent.
ELIGIBLE CLASS FOR DEPENDENT INSURANCE.Each Member of the eligible class(es) for dependent
coverage is eligible for the Dependent Insurance under the policy and will qualify for this Dependent Insurance on
the first of the month falling on or next following the latest of:
1. the day he or she qualifies for coverage as a Member;
2. the day he or she first becomes a Member; or
3. the day he or she first has a dependent. For dependent children, a newborn child will be
considered an eligible dependent upon reaching their 2
nd birthday. The child may be added at
birth or within 31 days of the 2
nd birthday.
A Member must be an Insured to also insure his or her dependents.
If employment is the basis for membership, a member of the Eligible Class for Dependent Insurance is any
eligible employees working at least 30 hours per week and has eligible dependents. If membership is by reason
other than employment, then a member of the Eligible Class for Insurance is as defined by the Policyholder.
Any husband or wife who elects to be a dependent rather than a member of the Eligible Class for Personal
Insurance, as explained above, is not a member of the Eligible Class for Dependent Insurance.
When a member of the Eligible Class for Dependent Insurance dies and, if at the date of death, has dependents
insured, the Policyholder has the option of offering the dependents of the deceased member continued coverage.
If elected by the Policyholder and the affected dependents, the name of such deceased member will continue to be
listed as a member of the Eligible Class for Dependent Insurance.
CONTRIBUTION REQUIREMENTS.Member Insurance: An Insured is not required to contribute to the
payment of his or her insurance premiums. An insured may or may not be required to contribute to the payment
of insurance premiums if he or she is both covered under this policy and also covered under another plan.
Dependent Insurance: An Insured is required to contribute to the payment of insurance premiums for his or her
dependents.
SECTION 125. (Dependents Only)This policy is provided as part of the Policyholder's Section 125 Plan.
Each Member has the option under the Section 125 Plan of participating or not participating in this policy.
If a Member does not elect to participate when initially eligible, the Member may elect to participate at the
Policyholder's next Election Period. This Election Period will be held each year and those who elect to participate
in this policy at that time will have their insurance become effective on September 1. A Member who elects to
participate during an Election Period who did not elect to participate when initially eligible will be a Late Entrant
and subject to Limitation No. 1 on 9219. (There is NO "open enrollment" under this policy.)
Members may change their election option only during an Election Period, except for a change in family status.
Such events would be marriage, divorce, birth of a child, death of a spouse or child, or termination of employment
of a spouse.
ELIGIBILITY PERIOD. For Members on the Plan Effective Date of the policy, coverage is effective
immediately.
For persons who become Members after the Plan Effective Date of the policy, qualification will occur on the first
of the month falling on or first following the eligibility period of 30 calendar day(s) of continuous active
membership.
If employment is the basis for membership in the Eligible Class for Members, an Insured whose eligibility
terminates and is established again, may or may not have to complete a new eligibility period before he or she can
again qualify for insurance.
ELIMINATION PERIOD.Certain covered expenses may be subject to an elimination period, please refer to
the TABLE OF DENTAL PROCEDURES, DENTAL EXPENSE BENEFITS, and if applicable, the
ORTHODONTIC EXPENSE BENEFITS pages for details.
EFFECTIVE DATE.Each Member has the option of being insured and insuring his or her Dependents. To
elect coverage, he or she must agree in writing to contribute to the payment of the insurance premiums. The
Effective Date for each Member and his or her Dependents, will be the first of the month falling on or next
following:
1. the date on which the Member qualifies for insurance, if the Member agrees to contribute on or
before that date.
2. the date on which the Member agrees to contribute, if that date is within 31 days after the date he or
she qualifies for insurance.
3. the date we accept the Member and/or Dependent for insurance when the Member and/or Dependent
is a Late Entrant. The Member and/or Dependent will be subject to any limitation concerning Late
Entrants.
EXCEPTIONS.If employment is the basis for membership, a Member must be in active service on the date the
insurance, or any increase in insurance, is to take effect. If not, the insurance will not take effect until the day he
or she returns to active service. Active service refers to the performance in the customary manner by an employee
of all the regular duties of his or her employment with his or her employer on a full time basis at one of the
employer's business establishments or at some location to which the employer's business requires the employee to
travel.
A Member will be in active service on any regular non-working day if he or she is not totally disabled on that day
and if he or she was in active service on the regular working day before that day.
If membership is by reason other than employment, a Member must not be totally disabled on the date the
insurance, or any increase in insurance, is to take effect. The insurance will not take effect until the day after he
or she ceases to be totally disabled.
TERMINATION DATES
INSUREDS.The insurance for any Insured, will automatically terminate on the end of the month falling on or
next following the earliest of:
1. the date the Insured ceases to be a Member;
2. the last day of the period for which the Insured has contributed, if required, to the payment of insurance
premiums; or
3. the date the policy is terminated.
DEPENDENTS.The insurance for all of an Insured’s dependents will automatically terminate on the end of the
month falling on or next following the earliest of:
1. the date on which the Insured's coverage terminates;
2. the date on which the Insured ceases to be a Member;
3. the last day of the period for which the Insured has contributed, if required, to the payment of insurance
premiums; or
4. the date all Dependent Insurance under the policy is terminated.
The insurance for any Dependent will automatically terminate on the end of the month falling on or next
following the day before the date on which the dependent no longer meets the definition of a dependent. See
"Definitions."
CONTINUATION OF COVERAGE.If coverage ceases according to TERMINATION DATE, some or all of
the insurance coverages may be continued. Contact your plan administrator for details.
Death or Divorce
For Dependents Only
1. The Insured's spouse may continue coverage for themselves and any dependent children if coverage would
terminate as a result of:
a. the death of the Insured; or
b. the dissolution of a marriage (divorce) with the Insured.
provided any required premium is paid.
2. Benefits
This continuation applies to all benefits payable under the policy.
3. Premiums
We may charge the full premium, i.e. the employee's and employer's portion during the continuation
period.
We may change the premium rate at any time the Insured's group plan premium rate is changed.
4. How to Apply
Within 31 days of death of the Insured or the date of the divorce, the spouse must notify the employer and
us in writing if he or she is electing to continue coverage.
5. Termination
Such insurance will stop on the earliest of:
a. the last day of the period for which the premium is paid;
b. the date coverage would normally stop under the terms of the policy;
c. the date the spouse becomes insured under another group health plan;
d. the date the spouse remarries and becomes insured under another group health plan;
e. the date the spouse or any dependent child is eligible for coverage under Medicare, Title XVIII of
the Federal Social Security Act;
f. the date the policy terminates.
If the Policyholder is subject to COBRA, then the termination of coverage will be controlled by COBRA or by
paragraph 5. above, whichever would provide a greater length of coverage.
9219 Takeover Ed. 01-05
DENTAL EXPENSE BENEFITS
We will determine dental expense benefits according to the terms of the group policy for dental expenses incurred
by an Insured. An Insured person has the freedom of choice to receive treatment from any Provider.
PARTICIPATING AND NON-PARTICIPATING PROVIDERS. The Insured person may select a
Participating Provider or a Non-Participating Provider. A Participating Provider agrees to provide services at a
discounted fee to our Insureds. A Non-Participating Provider is any other Provider.
DETERMINING BENEFITS.The benefits payable will be determined by totaling all of the Covered Expenses
submitted into each benefit type as shown in the Table of Dental Procedures. This amount is reduced by the
Deductible, if any. The result is then multiplied by the Coinsurance Percentage(s) shown in the Schedule of
Benefits. Benefits are subject to the Maximum Amount, if any, shown in the Schedule of Benefits.
BENEFIT PERIOD.Benefit Period refers to the period shown in the Table of Dental Procedures.
DEDUCTIBLE.The Deductible is shown on the Schedule of Benefits and is a specified amount of Covered
Expenses that must be incurred and paid by each Insured person prior to any benefits being paid.
MAXIMUM AMOUNT.The Maximum Amount shown in the Schedule of Benefits is the maximum amount
that may be paid for the Covered Expenses incurred by an Insured.
COVERED EXPENSES.Covered Expenses include:
1. only those expenses for dental procedures performed by a Provider; and
2. only those expenses for dental procedures listed and outlined on the Table of Dental Procedures.
Covered Expenses are subject to "Limitations." See Limitations and Table of Dental Procedures.
Benefits payable for Covered Expenses also will be limited to the lesser of:
1. the actual charge of the Provider.
2. the usual and customary ("U&C") as determined by us, if services are provided by a Non Participating
Provider.
3. the Maximum Allowable Charge ("MAC") as determined by us.
Usual and Customary (“U&C”) describes those dental charges that we have determined to be the usual and
customary charge for a given dental procedure within a particular ZIP code area. The U&C is based upon a
combination of dental charge information taken from our own database as well as from data received from
nationally recognized industry databases. From the array of charges ranked by amount, your Policyholder (in
most cases your employer) has selected a percentile that will be used to determine the maximum U&C for your
plan. The U&C is reviewed and updated periodically. The U&C can differ from the actual fee charged by your
provider and is not indicative of the appropriateness of the provider’s fee. Instead, the U&C is simply a plan
provision used to determine the extent of benefit coverage purchased by your Policyholder.
MAC - The Maximum Allowable Charge is derived from the array of provider charges within a particular ZIP
code area. These allowances are the charges accepted by general dentists who are Participating Providers. The
MAC is reviewed and updated periodically to reflect increasing provider fees within the ZIP code area.
ALTERNATIVE PROCEDURES.If two or more procedures are considered adequate and appropriate
treatment to correct a certain condition under generally accepted standards of dental care, the amount of the
Covered Expense will be equal to the charge for the least expensive procedure. This provision is NOT intended to
dictate a course of treatment. Instead, this provision is designed to determine the amount of the plan allowance
for a submitted treatment when an adequate and appropriate alternative procedure is available. Accordingly, you
may choose to apply the alternate benefit amount determined under this provision toward payment of the
submitted treatment.
We may request pre-operative dental x-ray films, periodontal charting and/or additional diagnostic data to
determine the plan allowance for the procedures submitted. We strongly encourage pre-treatment estimates so you
understand your benefits before any treatment begins. Ask your provider to submit a claim form for this purpose.
EXPENSES INCURRED.An expense is incurred at the time the impression is made for an appliance or change
to an appliance. An expense is incurred at the time the tooth or teeth are prepared for a prosthetic crown,
appliance, or fixed partial denture. For root canal therapy, an expense is incurred at the time the pulp chamber is
opened. All other expenses are incurred at the time the service is rendered or a supply furnished.
LIMITATIONS.Covered Expenses will not include and benefits will not be payable for expenses incurred:
1. in the first 12 months that a person is insured if the person is a Late Entrant; except for evaluations,
prophylaxis (cleanings), and fluoride application.
2. a. for initial placement of any prosthetic crown, appliance, or fixed partial denture unless such
placement is needed because of the extraction of one or more teeth while the insured person is covered
under this contract. But the extraction of a third molar (wisdom tooth) will not qualify under the above.
Any such prosthetic crown, appliance, or fixed partial denture must include the replacement of the
extracted tooth or teeth, unless the insured person is covered on September 1, 2006. For those Insureds
covered on September 1, 2006, see b.
b. Limitation a. will be waived for those Insureds whose coverage was effective on September 1,
2006 and
i. the person has the tooth extracted while insured under the prior contract: and
ii. has a prosthetic crown, appliance, or fixed partial denture installed to replace the extracted
tooth while insured under our contract;
but such extraction and installation must take place within a six-month period; and
iii. the prosthetic crown, appliance, or fixed partial denture noted above must be an initial
placement.
3. for appliances, restorations, or procedures to:
a. alter vertical dimension;
b. restore or maintain occlusion; or
c. splint or replace tooth structure lost as a result of abrasion or attrition.
4. for any procedure begun after the insured person's insurance under this contract terminates; or for any
prosthetic dental appliances installed or delivered more than 90 days after the Insured's insurance under
this contract terminates.
5. to replace lost or stolen appliances.
6. for any treatment which is for cosmetic purposes.
7. for any procedure not shown in the Table of Dental Procedures. (There may be additional frequencies
and limitations that apply, please see the Table of Dental Procedures for details.)
8. for orthodontic treatment under this benefit provision. (If orthodontic expense benefits have been
included in this policy, please refer to the Schedule of Benefits and Orthodontic Expense Benefits
provision found on 9260).
9. for which the Insured person is entitled to benefits under any workmen’s compensation or similar law,
or charges for services or supplies received as a result of any dental condition caused or contributed to
by an injury or sickness arising out of or in the course of any employment for wage or profit.
10. for charges which the Insured person is not liable or which would not have been made had no insurance
been in force.
11. for services that are not required for necessary care and treatment or are not within the generally
accepted parameters of care.
12. because of war or any act of war, declared or not.
9232
TABLE OF DENTAL PROCEDURES
PLEASE READ THE FOLLOWING INFORMATION CAREFULLY FOR YOUR PROCEDURE
FREQUENCIES AND PROVISIONS.
The attached is a list of dental procedures for which benefits are payable under this section; and is based upon the
Current Dental Terminology, (CDT-5), copyrighted 2004, American Dental Association.No benefits are
payable for a procedure that is not listed.
Your benefits are based on a Calendar Year. A Calendar Year runs from January 1 through December 31.
Benefit Period means the period from January 1 of any year through December 31 of the same year. But
during the first year a person is insured, a benefit period means the period from his or her effective date
through December 31 of that year.
Covered Procedures are subject to all plan provisions, procedure and frequency limitations, and/or
consultant review.
Reference to "traumatic injury" under this plan is defined as injury caused by external forces (ie. outside
the mouth) and specifically excludes injury caused by internal forces such as bruxism (grinding of teeth).
Benefits for replacement prosthetic crown, appliance, or fixed partial denture will be based on the prior
placement date. Frequencies which reference Benefit Period will be measured forward within the limits
defined as the Benefit Period. All other frequencies will be measured forward from the last covered date
of service.
X-ray films, periodontal charting and supporting diagnostic data may be requested for our review.
We recommend that a pre-treatment estimate be submitted for all anticipated work that is considered to be
expensive by our insured.
A pre-treatment estimate is not a pre-authorization or guarantee of payment or eligibility; rather it is an
indication of the estimated benefits available if the described procedures are performed.
TYPE 1 PROCEDURES
PAYMENT BASIS - NON PARTICIPATING PROVIDER - Usual and Customary
BENEFIT PERIOD - Calendar Year
For Additional Limitations - See Limitations
ROUTINE ORAL EVALUATION
D0120 Periodic oral evaluation.
D0150 Comprehensive oral evaluation - new or established patient.
D0180 Comprehensive periodontal evaluation - new or established patient.
COMPREHENSIVE EVALUATION: D0150, D0180
•Coverage is limited to 1 of each of these procedures per 1 provider.
•In addition, D0150, D0180 coverage is limited to 2 of any of these procedures per 1 benefit period.
•D0120, also contribute(s) to this limitation.
•If frequency met, will be considered at an alternate benefit of a D0120 and count toward this frequency.
ROUTINE EVALUATION: D0120
•Coverage is limited to 2 of any of these procedures per 1 benefit period.
•D0150, D0180, also contribute(s) to this limitation.
COMPLETE SERIES OR PANORAMIC FILM
D0210 Intraoral - complete series (including bitewings).
D0330 Panoramic film.
COMPLETE SERIES/PANORAMIC FILMS: D0210, D0330
•Coverage is limited to 1 of any of these procedures per 3 year(s).
OTHER XRAYS
D0220 Intraoral - periapical first film.
D0230 Intraoral - periapical each additional film.
D0240 Intraoral - occlusal film.
D0250 Extraoral - first film.
D0260 Extraoral - each additional film.
PERIAPICAL FILMS: D0220, D0230
•The maximum amount considered for x-ray films taken on one day will be equivalent to an allowance of a D0210.
BITEWING FILMS
D0270 Bitewing - single film.
D0272 Bitewings - two films.
D0274 Bitewings - four films.
D0277 Vertical bitewings - 7 to 8 films.
BITEWING FILMS: D0270, D0272, D0274
•Coverage is limited to 2 of any of these procedures per 1 benefit period.
•D0277, also contribute(s) to this limitation.
•The maximum amount considered for x-ray films taken on one day will be equivalent to an allowance of a D0210.
VERTICAL BITEWING FILM: D0277
•Coverage is limited to 1 of any of these procedures per 3 year(s).
•The maximum amount considered for x-ray films taken on one day will be equivalent to an allowance of a D0210.
PROPHYLAXIS (CLEANING) AND FLUORIDE
D1110 Prophylaxis - adult.
D1120 Prophylaxis - child.
D1201 Topical application of fluoride (including prophylaxis) - child.
D1203 Topical application of fluoride (prophylaxis not included) - child.
D1204 Topical application of fluoride (prophylaxis not included) - adult.
D1205 Topical application of fluoride (including prophylaxis) - adult.
FLUORIDE: D1201, D1203, D1204, D1205
•Coverage is limited to 1 of any of these procedures per 1 benefit period.
•Benefits are considered for persons age 18 and under.
•In addition, D1201, D1205 coverage is limited to 2 of any of these procedures per 1 benefit period.
•D1110, D1120, D4910, also contribute(s) to this limitation.
•The frequency limitation will not be exceeded for either Fluoride or Prophylaxis (cleaning).
PROPHYLAXIS: D1110, D1120
TYPE 1 PROCEDURES
•Coverage is limited to 2 of any of these procedures per 1 benefit period.
•D1201, D1205, D4910, also contribute(s) to this limitation.
•An adult prophylaxis (cleaning) is considered for individuals age 14 and over. A child prophylaxis (cleaning) is
considered for individuals age 13 and under. Benefits for prophylaxis (cleaning) are not available when performed on
the same date as periodontal procedures.
SPACE MAINTAINERS
D1510 Space maintainer - fixed - unilateral.
D1515 Space maintainer - fixed - bilateral.
D1520 Space maintainer - removable - unilateral.
D1525 Space maintainer - removable - bilateral.
D1550 Re-cementation of space maintainer.
SPACE MAINTAINER: D1510, D1515, D1520, D1525
•Coverage is limited to space maintenance for unerupted teeth, following extraction of primary teeth. Allowances include
all adjustments within 6 months of placement date.
APPLIANCE THERAPY
D8210 Removable appliance therapy.
D8220 Fixed appliance therapy.
APPLIANCE THERAPY: D8210, D8220
•Coverage is limited to the correction of thumb-sucking.
TYPE 2 PROCEDURES
PAYMENT BASIS - NON PARTICIPATING PROVIDER - Usual and Customary
BENEFIT PERIOD - Calendar Year
For Additional Limitations - See Limitations
LIMITED ORAL EVALUATION
D0140 Limited oral evaluation - problem focused.
D0170 Re-evaluation - limited, problem focused (established patient; not post-operative visit).
LIMITED ORAL EVALUATION: D0140, D0170
•Coverage is allowed for accidental injury only. If not due to an accident, will be considered at an alternate benefit of a
D0120 and count towards this frequency.
ORAL PATHOLOGY/LABORATORY
D0472 Accession of tissue, gross examination, preparation and transmission of written report.
D0473 Accession of tissue, gross and microscopic examination, preparation and transmission
of written report.
D0474 Accession of tissue, gross and microscopic examination, including assessment of
surgical margins for presence of disease, preparation and transmission of written
report.
ORAL PATHOLOGY LABORATORY: D0472, D0473, D0474
•Coverage is limited to 1 of any of these procedures per 12 month(s).
•Coverage is limited to 1 examination per biopsy/excision.
SEALANT
D1351 Sealant - per tooth.
SEALANT: D1351
•Coverage is limited to 1 of any of these procedures per 3 year(s).
•Benefits are considered for persons age 16 and under.
•Benefits are considered on permanent molars only.
•Coverage is allowed on the occlusal surface only.
AMALGAM RESTORATIONS (FILLINGS)
D2140 Amalgam - one surface, primary or permanent.
D2150 Amalgam - two surfaces, primary or permanent.
D2160 Amalgam - three surfaces, primary or permanent.
D2161 Amalgam - four or more surfaces, primary or permanent.
AMALGAM RESTORATIONS: D2140, D2150, D2160, D2161
•Coverage is limited to 1 of any of these procedures per 6 month(s).
•D2330, D2331, D2332, D2335, D2391, D2392, D2393, D2394, D9911, also contribute(s) to this limitation.
RESIN RESTORATIONS (FILLINGS)
D2330 Resin-based composite - one surface, anterior.
D2331 Resin-based composite - two surfaces, anterior.
D2332 Resin-based composite - three surfaces, anterior.
D2335 Resin-based composite - four or more surfaces or involving incisal angle (anterior).
D2391 Resin-based composite - one surface, posterior.
D2392 Resin-based composite - two surfaces, posterior.
D2393 Resin-based composite - three surfaces, posterior.
D2394 Resin-based composite - four or more surfaces, posterior.
D2410 Gold foil - one surface.
D2420 Gold foil - two surfaces.
D2430 Gold foil - three surfaces.
COMPOSITE RESTORATIONS: D2330, D2331, D2332, D2335, D2391, D2392, D2393, D2394
•Coverage is limited to 1 of any of these procedures per 6 month(s).
•D2140, D2150, D2160, D2161, D9911, also contribute(s) to this limitation.
•Porcelain and resin benefits are considered for anterior and bicuspid teeth only.
•Coverage is limited to necessary placement resulting from decay or replacement due to existing unserviceable
restorations.
TYPE 2 PROCEDURES
GOLD FOIL RESTORATIONS: D2410, D2420, D2430
•Gold foils are considered at an alternate benefit of an amalgam/composite restoration.
STAINLESS STEEL CROWN (PREFABRICATED CROWN)
D2390 Resin-based composite crown, anterior.
D2930 Prefabricated stainless steel crown - primary tooth.
D2931 Prefabricated stainless steel crown - permanent tooth.
D2932 Prefabricated resin crown.
D2933 Prefabricated stainless steel crown with resin window.
D2934 Prefabricated esthetic coated stainless steel crown - primary tooth.
STAINLESS STEEL CROWN: D2390, D2930, D2931, D2932, D2933, D2934
•Replacement is limited to 1 of any of these procedures per 12 month(s).
•Porcelain and resin benefits are considered for anterior and bicuspid teeth only.
RECEMENT
D2910 Recement inlay, onlay, or partial coverage restoration.
D2915 Recement cast or prefabricated post and core.
D2920 Recement crown.
D6930 Recement fixed partial denture.
SEDATIVE FILLING
D2940 Sedative filling.
ENDODONTICS MISCELLANEOUS
D3220 Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the
dentinocemental junction and application of medicament.
D3221 Pulpal debridement, primary and permanent teeth.
D3230 Pulpal therapy (resorbable filling)- anterior, primary tooth (excluding final
restoration).
D3240 Pulpal therapy (resorbable filling) -posterior, primary tooth (excluding final
restoration).
D3333 Internal root repair of perforation defects.
D3351 Apexification/recalcification - initial visit (apical closure/calcific repair of
perforations, root resorption, etc.)
D3352 Apexication/recalcification - interim medication replacement (apical closure/calcific
repair of perforations, root resorption, etc.).
D3353 Apexification/recalcification - final visit (includes completed root canal therapy -
apical closure/calcific repair of perforations, root resorption, etc.).
D3430 Retrograde filling - per root.
D3450 Root amputation - per root.
D3920 Hemisection (including any root removal), not including root canal therapy.
ENDODONTICS MISCELLANEOUS: D3333, D3430, D3450, D3920
•Procedure D3333 is limited to permanent teeth only.
PULPOTOMY/PULPAL DEBRIDEMENT/PULPAL THERAPY: D3220, D3221, D3230, D3240
•Procedure D3220 is limited to primary teeth.
ENDODONTIC THERAPY (ROOT CANALS)
D3310 Anterior (excluding final restoration).
D3320 Bicuspid (excluding final restoration).
D3330 Molar (excluding final restoration).
D3332 Incomplete endodontic therapy; inoperable, unrestorable or fractured tooth.
D3346 Retreatment of previous root canal therapy - anterior.
D3347 Retreatment of previous root canal therapy - bicuspid.
D3348 Retreatment of previous root canal therapy - molar.
ROOT CANALS: D3310, D3320, D3330, D3332
•Benefits are considered on permanent teeth only.
TYPE 2 PROCEDURES
•Allowances include intraoperative films and cultures but exclude final restoration.
RETREATMENT OF ROOT CANAL: D3346, D3347, D3348
•Coverage is limited to 1 of any of these procedures per 12 month(s).
•D3310, D3320, D3330, also contribute(s) to this limitation.
•Benefits are considered on permanent teeth only.
•Coverage is limited to service dates more than 12 months after root canal therapy. Allowances include intraoperative
films and cultures but exclude final restoration.
SURGICAL ENDODONTICS
D3410 Apicoectomy/periradicular surgery - anterior.
D3421 Apicoectomy/periradicular surgery - bicuspid (first root).
D3425 Apicoectomy/periradicular surgery - molar (first root).
D3426 Apicoectomy/periradicular surgery (each additional root).
SURGICAL PERIODONTICS
D4210 Gingivectomy or gingivoplasty - four or more contiguous teeth or bounded teeth
spaces per quadrant.
D4211 Gingivectomy or gingivoplasty - one to three contiguous teeth or bounded teeth spaces
per quadrant.
D4240 Gingival flap procedure, including root planing - four or more contiguous teeth or
bounded teeth spaces per quadrant.
D4241 Gingival flap procedure, including root planing - one to three contiguous teeth or
bounded teeth spaces per quadrant.
D4260 Osseous surgery (including flap entry and closure) - four or more contiguous teeth or
bounded teeth spaces per quadrant.
D4261 Osseous surgery (including flap entry and closure) - one to three contiguous teeth or
bounded teeth spaces per quadrant.
D4263 Bone replacement graft - first site in quadrant.
D4264 Bone replacement graft - each additional site in quadrant.
D4265 Biologic materials to aid in soft and osseous tissue regeneration.
D4270 Pedicle soft tissue graft procedure.
D4271 Free soft tissue graft procedure (including donor site surgery).
D4273 Subepithelial connective tissue graft procedures, per tooth.
D4274 Distal or proximal wedge procedure (when not performed in conjunction with surgical
procedures in the same anatomical area).
D4275 Soft tissue allograft.
D4276 Combined connective tissue and double pedicle graft, per tooth.
BONE GRAFTS: D4263, D4264, D4265
•Each quadrant is limited to 1 of each of these procedures per 3 year(s).
•Coverage is limited to treatment of periodontal disease.
GINGIVECTOMY: D4210, D4211
•Each quadrant is limited to 1 of each of these procedures per 3 year(s).
•Coverage is limited to treatment of periodontal disease.
OSSEOUS SURGERY: D4240, D4241, D4260, D4261
•Each quadrant is limited to 1 of each of these procedures per 3 year(s).
•Coverage is limited to treatment of periodontal disease.
TISSUE GRAFTS: D4270, D4271, D4273, D4275, D4276
•Each quadrant is limited to 2 of any of these procedures per 3 year(s).
•Coverage is limited to treatment of periodontal disease.
NON-SURGICAL PERIODONTICS
D4341 Periodontal scaling and root planing - four or more teeth per quadrant.
D4342 Periodontal scaling and root planing - one to three teeth, per quadrant.
D4381 Localized delivery of antimicrobial agents via a controlled release vehicle into
diseased crevicular tissue, per tooth, by report.
CHEMOTHERAPEUTIC AGENTS: D4381
•Each quadrant is limited to 2 of any of these procedures per 2 year(s).
•A scaling and root planing or periodontal maintenance procedure must be performed in this quadrant within 2 years
prior to the date of service for this procedure.
TYPE 2 PROCEDURES
PERIODONTAL SCALING & ROOT PLANING: D4341, D4342
•Each quadrant is limited to 1 of each of these procedures per 2 year(s).
FULL MOUTH DEBRIDEMENT
D4355 Full mouth debridement to enable comprehensive evaluation and diagnosis.
FULL MOUTH DEBRIDEMENT: D4355
•Coverage is limited to 1 of any of these procedures per 5 year(s).
PERIODONTAL MAINTENANCE
D4910 Periodontal maintenance.
PERIODONTAL MAINTENANCE: D4910
•Coverage is limited to 2 of any of these procedures per 1 benefit period.
•D1110, D1120, D1201, D1205, also contribute(s) to this limitation.
•Coverage is contingent upon evidence of full mouth active periodontal therapy. Benefits are not available if performed
on the same date as any other periodontal procedure.
DENTURE REPAIR
D5510 Repair broken complete denture base.
D5520 Replace missing or broken teeth - complete denture (each tooth).
D5610 Repair resin denture base.
D5620 Repair cast framework.
D5630 Repair or replace broken clasp.
D5640 Replace broken teeth - per tooth.
DENTURE RELINES
D5730 Reline complete maxillary denture (chairside).
D5731 Reline complete mandibular denture (chairside).
D5740 Reline maxillary partial denture (chairside).
D5741 Reline mandibular partial denture (chairside).
D5750 Reline complete maxillary denture (laboratory).
D5751 Reline complete mandibular denture (laboratory).
D5760 Reline maxillary partial denture (laboratory).
D5761 Reline mandibular partial denture (laboratory).
DENTURE RELINE: D5730, D5731, D5740, D5741, D5750, D5751, D5760, D5761
•Coverage is limited to service dates more than 6 months after placement date.
NON-SURGICAL EXTRACTIONS
D7111 Extraction, coronal remnants - deciduous tooth.
D7140 Extraction, erupted tooth or exposed root (elevation and/or forceps removal).
SURGICAL EXTRACTIONS
D7210 Surgical removal of erupted tooth requiring elevation of mucoperiosteal flap and
removal of bone and/or section of tooth.
D7220 Removal of impacted tooth - soft tissue.
D7230 Removal of impacted tooth - partially bony.
D7240 Removal of impacted tooth - completely bony.
D7241 Removal of impacted tooth - completely bony, with unusual surgical complications.
D7250 Surgical removal of residual tooth roots (cutting procedure).
OTHER ORAL SURGERY
D7260 Oroantral fistula closure.
D7261 Primary closure of a sinus perforation.
D7270 Tooth reimplantation and/or stabilization of accidentally evulsed or displaced tooth.
D7272 Tooth transplantation (includes reimplantation from one site to another and splinting
and/or stabilization).
D7280 Surgical access of an unerupted tooth.
TYPE 2 PROCEDURES
D7282 Mobilization of erupted or malpositioned tooth to aid eruption.
D7283 Placement of device to facilitate eruption of impacted tooth.
D7310 Alveoloplasty in conjunction with extractions - per quadrant.
D7311 Alveoplasty in conjunction with extractions - one to three teeth or tooth spaces, per
quadrant.
D7320 Alveoloplasty not in conjunction with extractions - per quadrant.
D7321 Alveoplasty not in conjunction with extractions - one to three teeth or tooth spaces, per
quadrant.
D7340 Vestibuloplasty - ridge extension (secondary epithelialization).
D7350 Vestibuloplasty - ridge extension (including soft tissue grafts, muscle reattachment,
revision of soft tissue attachment and management of hypertrophied and hyperplastic
tissue).
D7410 Excision of benign lesion up to 1.25 cm.
D7411 Excision of benign lesion greater than 1.25 cm.
D7412 Excision of benign lesion, complicated.
D7413 Excision of malignant lesion up to 1.25 cm.
D7414 Excision of malignant lesion greater than 1.25 cm.
D7415 Excision of malignant lesion, complicated.
D7440 Excision of malignant tumor - lesion diameter up to 1.25 cm.
D7441 Excision of malignant tumor - lesion diameter greater than 1.25 cm.
D7450 Removal of benign odontogenic cyst or tumor - lesion diameter up to 1.25 cm.
D7451 Removal of benign odontogenic cyst or tumor - lesion diameter greater than 1.25 cm.
D7460 Removal of benign nonodontogenic cyst or tumor - lesion diameter up to 1.25 cm.
D7461 Removal of benign nonodontogenic cyst or tumor - lesion diameter greater than 1.25
cm.
D7465 Destruction of lesion(s) by physical or chemical method, by report.
D7471 Removal of lateral exostosis (maxilla or mandible).
D7472 Removal of torus palatinus.
D7473 Removal of torus mandibularis.
D7485 Surgical reduction of osseous tuberosity.
D7490 Radical resection of maxilla or mandible.
D7510 Incision and drainage of abscess - intraoral soft tissue.
D7520 Incision and drainage of abscess - extraoral soft tissue.
D7530 Removal of foreign body from mucosa, skin, or subcutaneous alveolar tissue.
D7540 Removal of reaction producing foreign bodies, musculoskeletal system.
D7550 Partial ostectomy/sequestrectomy for removal of non-vital bone.
D7560 Maxillary sinusotomy for removal of tooth fragment or foreign body.
D7910 Suture of recent small wounds up to 5 cm.
D7911 Complicated suture - up to 5 cm.
D7912 Complicated suture - greater than 5 cm.
D7960 Frenulectomy (frenectomy or frenotomy) - separate procedure.
D7963 Frenuloplasty.
D7970 Excision of hyperplastic tissue - per arch.
D7972 Surgical reduction of fibrous tuberosity.
D7980 Sialolithotomy.
D7983 Closure of salivary fistula.
REMOVAL OF BONE TISSUE: D7471, D7472, D7473
•Coverage is limited to 5 of any of these procedures per 1 lifetime.
BIOPSY OF ORAL TISSUE
D7285 Biopsy of oral tissue - hard (bone, tooth).
D7286 Biopsy of oral tissue - soft.
D7287 Exfoliative cytological sample collection.
D7288 Brush biopsy - transepithelial sample collection.
TYPE 2 PROCEDURES
PALLIATIVE
D9110 Palliative (emergency) treatment of dental pain - minor procedure.
PALLIATIVE TREATMENT: D9110
•Not covered in conjunction with other procedures, except diagnostic x-ray films.
ANESTHESIA-GENERAL/IV
D9220 Deep sedation/general anesthesia - first 30 minutes.
D9221 Deep sedation/general anesthesia - each additional 15 minutes.
D9241 Intravenous conscious sedation/analgesia - first 30 minutes.
D9242 Intravenous conscious sedation/analgesia - each additional 15 minutes.
GENERAL ANESTHESIA: D9220, D9221, D9241, D9242
•Coverage is only available with a cutting procedure. Verification of the dentist's anesthesia permit and a copy of the
anesthesia report is required. A maximum of two additional units (D9221 or D9242) will be considered.
PROFESSIONAL CONSULT/VISIT/SERVICES
D9310 Consultation (diagnostic service provided by dentist or physician other than
practitioner providing treatment).
D9430 Office visit for observation (during regularly scheduled hours) - no other services
performed.
D9440 Office visit - after regularly scheduled hours.
D9930 Treatment of complications (post-surgical) - unusual circumstances, by report.
CONSULTATION: D9310
•Coverage is limited to 1 of any of these procedures per 1 provider.
OFFICE VISIT: D9430, D9440
•Procedure D9430 is allowed for accidental injury only. Procedure D9440 will be allowed on the basis of services
rendered or visit, whichever is greater.
OCCLUSAL ADJUSTMENT
D9951 Occlusal adjustment - limited.
D9952 Occlusal adjustment - complete.
OCCLUSAL ADJUSTMENT: D9951, D9952
•Coverage is considered only when performed in conjunction with periodontal procedures for the treatment of
periodontal disease.
MISCELLANEOUS
D2951 Pin retention - per tooth, in addition to restoration.
D9911 Application of desensitizing resin for cervical and/or root surfaces, per tooth.
DESENSITIZATION: D9911
•Coverage is limited to 1 of any of these procedures per 6 month(s).
•D2140, D2150, D2160, D2161, D2330, D2331, D2332, D2335, D2391, D2392, D2393, D2394, also contribute(s) to
this limitation.
•Porcelain and resin benefits are considered for anterior and bicuspid teeth only.
•Coverage is limited to necessary placement resulting from decay or replacement due to existing unserviceable
restorations.
TYPE 3 PROCEDURES
PAYMENT BASIS - NON PARTICIPATING PROVIDER - Usual and Customary
BENEFIT PERIOD - Calendar Year
For Additional Limitations - See Limitations
INLAY RESTORATIONS
D2510 Inlay - metallic - one surface.
D2520 Inlay - metallic - two surfaces.
D2530 Inlay - metallic - three or more surfaces.
D2610 Inlay - porcelain/ceramic - one surface.
D2620 Inlay - porcelain/ceramic - two surfaces.
D2630 Inlay - porcelain/ceramic - three or more surfaces.
D2650 Inlay - resin-based composite - one surface.
D2651 Inlay - resin-based composite - two surfaces.
D2652 Inlay - resin-based composite - three or more surfaces.
INLAY: D2510, D2520, D2530, D2610, D2620, D2630, D2650, D2651, D2652
•Inlays will be considered at an alternate benefit of an amalgam/composite restoration and only when resulting from
caries (tooth decay) or traumatic injury.
ONLAY RESTORATIONS
D2542 Onlay - metallic - two surfaces.
D2543 Onlay - metallic - three surfaces.
D2544 Onlay - metallic - four or more surfaces.
D2642 Onlay - porcelain/ceramic - two surfaces.
D2643 Onlay - porcelain/ceramic - three surfaces.
D2644 Onlay - porcelain/ceramic - four or more surfaces.
D2662 Onlay - resin-based composite - two surfaces.
D2663 Onlay - resin-based composite - three surfaces.
D2664 Onlay - resin-based composite - four or more surfaces.
ONLAY: D2542, D2543, D2544, D2642, D2643, D2644, D2662, D2663, D2664
•Replacement is limited to 1 of any of these procedures per 5 year(s).
•D2510, D2520, D2530, D2610, D2620, D2630, D2650, D2651, D2652, D2710, D2712, D2720, D2721, D2722,
D2740, D2750, D2751, D2752, D2780, D2781, D2782, D2783, D2790, D2791, D2792, D2794, D6600, D6601,
D6602, D6603, D6604, D6605, D6606, D6607, D6608, D6609, D6610, D6611, D6612, D6613, D6614, D6615,
D6624, D6634, D6710, D6720, D6721, D6722, D6740, D6750, D6751, D6752, D6780, D6781, D6782, D6783,
D6790, D6791, D6792, D6794, also contribute(s) to this limitation.
•Frequency is waived for accidental injury.
•Porcelain and resin benefits are considered for anterior and bicuspid teeth only.
•Coverage is limited to necessary placement resulting from caries (tooth decay) or traumatic injury.
•Benefits will not be considered if procedure D2390, D2930, D2931, D2932, D2933 or D2934 has been performed
within 12 months.
CROWNS SINGLE RESTORATIONS
D2710 Crown - resin-based composite (indirect).
D2712 Crown - 3/4 resin-based composite (indirect).
D2720 Crown - resin with high noble metal.
D2721 Crown - resin with predominantly base metal.
D2722 Crown - resin with noble metal.
D2740 Crown - porcelain/ceramic substrate.
D2750 Crown - porcelain fused to high noble metal.
D2751 Crown - porcelain fused to predominantly base metal.
D2752 Crown - porcelain fused to noble metal.
D2780 Crown - 3/4 cast high noble metal.
D2781 Crown - 3/4 cast predominantly base metal.
D2782 Crown - 3/4 cast noble metal.
D2783 Crown - 3/4 porcelain/ceramic.
D2790 Crown - full cast high noble metal.
TYPE 3 PROCEDURES
D2791 Crown - full cast predominantly base metal.
D2792 Crown - full cast noble metal.
D2794 Crown - titanium.
CROWN: D2710, D2712, D2720, D2722, D2740, D2750, D2751, D2752, D2780, D2781, D2782, D2783, D2790, D2791, D2792, D2794
•Replacement is limited to 1 of any of these procedures per 5 year(s).
•D2510, D2520, D2530, D2542, D2543, D2544, D2610, D2620, D2630, D2642, D2643, D2644, D2650, D2651,
D2652, D2662, D2663, D2664, D6600, D6601, D6602, D6603, D6604, D6605, D6606, D6607, D6608, D6609,
D6610, D6611, D6612, D6613, D6614, D6615, D6624, D6634, D6710, D6720, D6721, D6722, D6740, D6750,
D6751, D6752, D6780, D6781, D6782, D6783, D6790, D6791, D6792, D6794, also contribute(s) to this limitation.
•Frequency is waived for accidental injury.
•Porcelain and resin benefits are considered for anterior and bicuspid teeth only.
•Procedures that contain titanium or high noble metal will be considered at the corresponding noble metal allowance.
•Coverage is limited to necessary placement resulting from caries (tooth decay) or traumatic injury.
•Benefits will not be considered if procedure D2390, D2930, D2931, D2932, D2933 or D2934 has been performed
within 12 months.
CORE BUILD-UP
D2950 Core buildup, including any pins.
D6973 Core build up for retainer, including any pins.
POST AND CORE
D2952 Cast post and core in addition to crown.
D2954 Prefabricated post and core in addition to crown.
FIXED CROWN AND PARTIAL DENTURE REPAIR
D2980 Crown repair, by report.
D6980 Fixed partial denture repair, by report.
CROWN LENGTHENING
D4249 Clinical crown lengthening - hard tissue.
PROSTHODONTICS - FIXED/REMOVABLE (DENTURES)
D5110 Complete denture - maxillary.
D5120 Complete denture - mandibular.
D5130 Immediate denture - maxillary.
D5140 Immediate denture - 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).
D5214 Mandibular partial denture - cast metal framework with resin denture bases (including
any conventional clasps, rests and teeth).
D5225 Maxillary partial denture - flexible base (including any clasps, rests and teeth).
D5226 Mandibular partial denture - flexible base (including any clasps, rests and teeth).
D5281 Removable unilateral partial denture - one piece cast metal (including clasps and
teeth).
D5670 Replace all teeth and acrylic on cast metal framework (maxillary).
D5671 Replace all teeth and acrylic on cast metal framework (mandibular).
D5810 Interim complete denture (maxillary).
D5811 Interim complete denture (mandibular).
D5820 Interim partial denture (maxillary).
D5821 Interim partial denture (mandibular).
D5860 Overdenture - complete, by report.
D5861 Overdenture - partial, by report.
TYPE 3 PROCEDURES
D6053 Implant/abutment supported removable denture for completely edentulous arch.
D6054 Implant/abutment supported removable denture for partially edentulous arch.
D6078 Implant/abutment supported fixed denture for completely edentulous arch.
D6079 Implant/abutment supported fixed denture for partially edentulous arch.
COMPLETE DENTURE: D5110, D5120, D5130, D5140, D5860, D6053, D6078
•Replacement is limited to 1 of any of these procedures per 5 year(s).
•Frequency is waived for accidental injury.
•Allowances include adjustments within 6 months after placement date. Procedures D5860, D6053, and D6078 are
considered at an alternate benefit of a D5110/D5120.
PARTIAL DENTURE: D5211, D5212, D5213, D5214, D5225, D5226, D5281, D5670, D5671, D5861, D6054, D6079
•Replacement is limited to 1 of any of these procedures per 5 year(s).
•Frequency is waived for accidental injury.
•Allowances include adjustments within 6 months of placement date. Procedures D5861, D6054, and D6079 are
considered at an alternate benefit of a D5213/D5214.
DENTURE ADJUSTMENTS
D5410 Adjust complete denture - maxillary.
D5411 Adjust complete denture - mandibular.
D5421 Adjust partial denture - maxillary.
D5422 Adjust partial denture - mandibular.
DENTURE ADJUSTMENT: D5410, D5411, D5421, D5422
•Coverage is limited to dates of service more than 6 months after placement date.
ADD TOOTH/CLASP TO EXISTING PARTIAL
D5650 Add tooth to existing partial denture.
D5660 Add clasp to existing partial denture.
DENTURE REBASES
D5710 Rebase complete maxillary denture.
D5711 Rebase complete mandibular denture.
D5720 Rebase maxillary partial denture.
D5721 Rebase mandibular partial denture.
TISSUE CONDITIONING
D5850 Tissue conditioning, maxillary.
D5851 Tissue conditioning, mandibular.
PROSTHODONTICS - FIXED
D6058 Abutment supported porcelain/ceramic crown.
D6059 Abutment supported porcelain fused to metal crown (high noble metal).
D6060 Abutment supported porcelain fused to metal crown (predominantly base metal).
D6061 Abutment supported porcelain fused to metal crown (noble metal).
D6062 Abutment supported cast metal crown (high noble metal).
D6063 Abutment supported cast metal crown (predominantly base metal).
D6064 Abutment supported cast metal crown (noble metal).
D6065 Implant supported porcelain/ceramic crown.
D6066 Implant supported porcelain fused to metal crown (titanium, titanium alloy, high noble
metal).
D6067 Implant supported metal crown (titanium, titanium alloy, high noble metal).
D6068 Abutment supported retainer for porcelain/ceramic FPD.
D6069 Abutment supported retainer for porcelain fused to metal FPD (high noble metal).
D6070 Abutment supported retainer for porcelain fused to metal FPD (predominantly base
metal).
D6071 Abutment supported retainer for porcelain fused to metal FPD (noble metal).
D6072 Abutment supported retainer for cast metal FPD (high noble metal).
D6073 Abutment supported retainer for cast metal FPD (predominantly base metal).
TYPE 3 PROCEDURES
D6074 Abutment supported retainer for cast metal FPD (noble metal).
D6075 Implant supported retainer for ceramic FPD.
D6076 Implant supported retainer for porcelain fused to metal FPD (titanium, titanium alloy,
or high noble metal).
D6077 Implant supported retainer for cast metal FPD (titanium, titanium alloy or high noble
metal).
D6094 Abutment supported crown - (titanium).
D6194 Abutment supported retainer crown for FPD - (titanium).
D6205 Pontic - indirect resin based composite.
D6210 Pontic - cast high noble metal.
D6211 Pontic - cast predominantly base metal.
D6212 Pontic - cast noble metal.
D6214 Pontic - titanium.
D6240 Pontic - porcelain fused to high noble metal.
D6241 Pontic - porcelain fused to predominantly base metal.
D6242 Pontic - porcelain fused to noble metal.
D6245 Pontic - porcelain/ceramic.
D6250 Pontic - resin with high noble metal.
D6251 Pontic - resin with predominantly base metal.
D6252 Pontic - resin with noble metal.
D6545 Retainer - cast metal for resin bonded fixed prosthesis.
D6548 Retainer - porcelain/ceramic for resin bonded fixed prosthesis.
D6600 Inlay - porcelain/ceramic, two surfaces.
D6601 Inlay - porcelain/ceramic, three or more surfaces.
D6602 Inlay - cast high noble metal, two surfaces.
D6603 Inlay - cast high noble metal, three or more surfaces.
D6604 Inlay - cast predominantly base metal, two surfaces.
D6605 Inlay - cast predominantly base metal, three or more surfaces.
D6606 Inlay - cast noble metal, two surfaces.
D6607 Inlay - cast noble metal, three or more surfaces.
D6608 Onlay - porcelain/ceramic, two surfaces.
D6609 Onlay - porcelain/ceramic, three or more surfaces.
D6610 Onlay - cast high noble metal, two surfaces.
D6611 Onlay - cast high noble metal, three or more surfaces.
D6612 Onlay - cast predominantly base metal, two surfaces.
D6613 Onlay - cast predominantly base metal, three or more surfaces.
D6614 Onlay - cast noble metal, two surfaces.
D6615 Onlay - cast noble metal, three or more surfaces.
D6624 Inlay - titanium.
D6634 Onlay - titanium.
D6710 Crown - indirect resin based composite.
D6720 Crown - resin with high noble metal.
D6721 Crown - resin with predominantly base metal.
D6722 Crown - resin with noble metal.
D6740 Crown - porcelain/ceramic.
D6750 Crown - porcelain fused to high noble metal.
D6751 Crown - porcelain fused to predominantly base metal.
D6752 Crown - porcelain fused to noble metal.
D6780 Crown - 3/4 cast high noble metal.
D6781 Crown - 3/4 cast predominantly base metal.
D6782 Crown - 3/4 cast noble metal.
D6783 Crown - 3/4 porcelain/ceramic.
D6790 Crown - full cast high noble metal.
TYPE 3 PROCEDURES
D6791 Crown - full cast predominantly base metal.
D6792 Crown - full cast noble metal.
D6794 Crown - titanium.
D6940 Stress breaker.
FIXED PARTIAL CROWN: D6710, D6720, D6721, D6722, D6740, D6750, D6751, D6752, D6780, D6781, D6782, D6783, D6790, D6791, D6792,
D6794
•Replacement is limited to 1 of any of these procedures per 5 year(s).
•D2510, D2520, D2530, D2542, D2543, D2544, D2610, D2620, D2630, D2642, D2643, D2644, D2650, D2651,
D2652, D2662, D2663, D2664, D2710, D2712, D2720, D2721, D2722, D2740, D2750, D2751, D2752, D2780,
D2781, D2782, D2783, D2790, D2791, D2792, D2794, D6600, D6601, D6602, D6603, D6604, D6605, D6606,
D6607, D6608, D6609, D6610, D6611, D6612, D6613, D6614, D6615, D6624, D6634, also contribute(s) to this
limitation.
•Frequency is waived for accidental injury.
•Porcelain and resin benefits are considered for anterior and bicuspid teeth only.
•Procedures that contain titanium or high noble metal will be considered at the corresponding noble metal allowance.
•Benefits will not be considered if procedure D2390, D2930, D2931, D2932, D2933 or D2934 has been performed
within 12 months.
FIXED PARTIAL INLAY: D6600, D6601, D6602, D6603, D6604, D6605, D6606, D6607, D6624
•Replacement is limited to 1 of any of these procedures per 5 year(s).
•D2510, D2520, D2530, D2542, D2543, D2544, D2610, D2620, D2630, D2642, D2643, D2644, D2650, D2651,
D2652, D2662, D2663, D2664, D2710, D2712, D2720, D2721, D2722, D2740, D2750, D2751, D2752, D2780,
D2781, D2782, D2783, D2790, D2791, D2792, D2794, D6608, D6609, D6610, D6611, D6612, D6613, D6614,
D6615, D6634, D6710, D6720, D6721, D6722, D6740, D6750, D6751, D6752, D6780, D6781, D6782, D6783,
D6790, D6791, D6792, D6794, also contribute(s) to this limitation.
•Frequency is waived for accidental injury.
•Porcelain and resin benefits are considered for anterior and bicuspid teeth only.
•Procedures that contain titanium or high noble metal will be considered at the corresponding noble metal allowance.
FIXED PARTIAL ONLAY: D6608, D6609, D6610, D6611, D6612, D6613, D6614, D6615, D6634
•Replacement is limited to 1 of any of these procedures per 5 year(s).
•D2510, D2520, D2530, D2542, D2543, D2544, D2610, D2620, D2630, D2642, D2643, D2644, D2650, D2651,
D2652, D2662, D2663, D2664, D2710, D2712, D2720, D2721, D2722, D2740, D2750, D2751, D2752, D2780,
D2781, D2782, D2783, D2790, D2791, D2792, D2794, D6600, D6601, D6602, D6603, D6604, D6605, D6606,
D6607, D6624, D6710, D6720, D6721, D6722, D6740, D6750, D6751, D6752, D6780, D6781, D6782, D6783,
D6790, D6791, D6792, D6794, also contribute(s) to this limitation.
•Frequency is waived for accidental injury.
•Porcelain and resin benefits are considered for anterior and bicuspid teeth only.
•Procedures that contain titanium or high noble metal will be considered at the corresponding noble metal allowance.
•Benefits will not be considered if procedure D2390, D2930, D2931, D2932, D2933 or D2934 has been performed
within 12 months.
FIXED PARTIAL PONTIC: D6205, D6210, D6211, D6212, D6214, D6240, D6241, D6242, D6245, D6250, D6251, D6252
•Replacement is limited to 1 of any of these procedures per 5 year(s).
•D5211, D5212, D5213, D5214, D5225, D5226, D5281, D6058, D6059, D6060, D6061, D6062, D6063, D6064,
D6065, D6066, D6067, D6068, D6069, D6070, D6071, D6072, D6073, D6074, D6075, D6076, D6077, D6094,
D6194, also contribute(s) to this limitation.
•Frequency is waived for accidental injury.
•Porcelain and resin benefits are considered for anterior and bicuspid teeth only.
•Procedures that contain titanium or high noble metal will be considered at the corresponding noble metal allowance.
IMPLANT SUPPORTED CROWN: D6058, D6059, D6060, D6061, D6062, D6063, D6064, D6065, D6066, D6067, D6094
•Replacement is limited to 1 of any of these procedures per 5 year(s).
•D5211, D5212, D5213, D5214, D5225, D5226, D5281, D6194, D6205, D6210, D6211, D6212, D6214, D6240,
D6241, D6242, D6245, D6250, D6251, D6252, also contribute(s) to this limitation.
•Frequency is waived for accidental injury.
•Porcelain and resin benefits are considered for anterior and bicuspid teeth only.
•Procedures that contain titanium or high noble metal will be considered at the corresponding noble metal allowance.
IMPLANT SUPPORTED RETAINER: D6068, D6069, D6070, D6071, D6072, D6073, D6074, D6075, D6076, D6077, D6194
•Replacement is limited to 1 of any of these procedures per 5 year(s).
•D5211, D5212, D5213, D5214, D5225, D5226, D5281, D6058, D6059, D6060, D6061, D6062, D6063, D6064,
D6065, D6066, D6067, D6094, D6205, D6210, D6211, D6212, D6214, D6240, D6241, D6242, D6245, D6250,
D6251, D6252, also contribute(s) to this limitation.
•Frequency is waived for accidental injury.
•Porcelain and resin benefits are considered for anterior and bicuspid teeth only.
•Procedures that contain titanium or high noble metal will be considered at the corresponding noble metal allowance.
CAST POST AND CORE FOR PARTIALS
D6970 Cast post and core in addition to fixed partial denture retainer.
D6971 Cast post as part of fixed partial denture retainer.
D6972 Prefabricated post and core in addition to fixed partial denture retainer.
TYPE 1 PROCEDURES
PAYMENT BASIS - PARTICIPATING PROVIDERS - Maximum Allowable Charge
BENEFIT PERIOD - Calendar Year
For Additional Limitations - See Limitations
ROUTINE ORAL EVALUATION
D0120 Periodic oral evaluation.
D0150 Comprehensive oral evaluation - new or established patient.
D0180 Comprehensive periodontal evaluation - new or established patient.
COMPREHENSIVE EVALUATION: D0150, D0180
•Coverage is limited to 1 of each of these procedures per 1 provider.
•In addition, D0150, D0180 coverage is limited to 2 of any of these procedures per 1 benefit period.
•D0120, also contribute(s) to this limitation.
•If frequency met, will be considered at an alternate benefit of a D0120 and count toward this frequency.
ROUTINE EVALUATION: D0120
•Coverage is limited to 2 of any of these procedures per 1 benefit period.
•D0150, D0180, also contribute(s) to this limitation.
COMPLETE SERIES OR PANORAMIC FILM
D0210 Intraoral - complete series (including bitewings).
D0330 Panoramic film.
COMPLETE SERIES/PANORAMIC FILMS: D0210, D0330
•Coverage is limited to 1 of any of these procedures per 3 year(s).
OTHER XRAYS
D0220 Intraoral - periapical first film.
D0230 Intraoral - periapical each additional film.
D0240 Intraoral - occlusal film.
D0250 Extraoral - first film.
D0260 Extraoral - each additional film.
PERIAPICAL FILMS: D0220, D0230
•The maximum amount considered for x-ray films taken on one day will be equivalent to an allowance of a D0210.
BITEWING FILMS
D0270 Bitewing - single film.
D0272 Bitewings - two films.
D0274 Bitewings - four films.
D0277 Vertical bitewings - 7 to 8 films.
BITEWING FILMS: D0270, D0272, D0274
•Coverage is limited to 2 of any of these procedures per 1 benefit period.
•D0277, also contribute(s) to this limitation.
•The maximum amount considered for x-ray films taken on one day will be equivalent to an allowance of a D0210.
VERTICAL BITEWING FILM: D0277
•Coverage is limited to 1 of any of these procedures per 3 year(s).
•The maximum amount considered for x-ray films taken on one day will be equivalent to an allowance of a D0210.
PROPHYLAXIS (CLEANING) AND FLUORIDE
D1110 Prophylaxis - adult.
D1120 Prophylaxis - child.
D1201 Topical application of fluoride (including prophylaxis) - child.
D1203 Topical application of fluoride (prophylaxis not included) - child.
D1204 Topical application of fluoride (prophylaxis not included) - adult.
D1205 Topical application of fluoride (including prophylaxis) - adult.
FLUORIDE: D1201, D1203, D1204, D1205
•Coverage is limited to 1 of any of these procedures per 1 benefit period.
•Benefits are considered for persons age 18 and under.
•In addition, D1201, D1205 coverage is limited to 2 of any of these procedures per 1 benefit period.
•D1110, D1120, D4910, also contribute(s) to this limitation.
•The frequency limitation will not be exceeded for either Fluoride or Prophylaxis (cleaning).
PROPHYLAXIS: D1110, D1120
TYPE 1 PROCEDURES
•Coverage is limited to 2 of any of these procedures per 1 benefit period.
•D1201, D1205, D4910, also contribute(s) to this limitation.
•An adult prophylaxis (cleaning) is considered for individuals age 14 and over. A child prophylaxis (cleaning) is
considered for individuals age 13 and under. Benefits for prophylaxis (cleaning) are not available when performed on
the same date as periodontal procedures.
SPACE MAINTAINERS
D1510 Space maintainer - fixed - unilateral.
D1515 Space maintainer - fixed - bilateral.
D1520 Space maintainer - removable - unilateral.
D1525 Space maintainer - removable - bilateral.
D1550 Re-cementation of space maintainer.
SPACE MAINTAINER: D1510, D1515, D1520, D1525
•Coverage is limited to space maintenance for unerupted teeth, following extraction of primary teeth. Allowances include
all adjustments within 6 months of placement date.
APPLIANCE THERAPY
D8210 Removable appliance therapy.
D8220 Fixed appliance therapy.
APPLIANCE THERAPY: D8210, D8220
•Coverage is limited to the correction of thumb-sucking.
TYPE 2 PROCEDURES
PAYMENT BASIS - PARTICIPATING PROVIDERS - Maximum Allowable Charge
BENEFIT PERIOD - Calendar Year
For Additional Limitations - See Limitations
LIMITED ORAL EVALUATION
D0140 Limited oral evaluation - problem focused.
D0170 Re-evaluation - limited, problem focused (established patient; not post-operative visit).
LIMITED ORAL EVALUATION: D0140, D0170
•Coverage is allowed for accidental injury only. If not due to an accident, will be considered at an alternate benefit of a
D0120 and count towards this frequency.
ORAL PATHOLOGY/LABORATORY
D0472 Accession of tissue, gross examination, preparation and transmission of written report.
D0473 Accession of tissue, gross and microscopic examination, preparation and transmission
of written report.
D0474 Accession of tissue, gross and microscopic examination, including assessment of
surgical margins for presence of disease, preparation and transmission of written
report.
ORAL PATHOLOGY LABORATORY: D0472, D0473, D0474
•Coverage is limited to 1 of any of these procedures per 12 month(s).
•Coverage is limited to 1 examination per biopsy/excision.
SEALANT
D1351 Sealant - per tooth.
SEALANT: D1351
•Coverage is limited to 1 of any of these procedures per 3 year(s).
•Benefits are considered for persons age 16 and under.
•Benefits are considered on permanent molars only.
•Coverage is allowed on the occlusal surface only.
AMALGAM RESTORATIONS (FILLINGS)
D2140 Amalgam - one surface, primary or permanent.
D2150 Amalgam - two surfaces, primary or permanent.
D2160 Amalgam - three surfaces, primary or permanent.
D2161 Amalgam - four or more surfaces, primary or permanent.
AMALGAM RESTORATIONS: D2140, D2150, D2160, D2161
•Coverage is limited to 1 of any of these procedures per 6 month(s).
•D2330, D2331, D2332, D2335, D2391, D2392, D2393, D2394, D9911, also contribute(s) to this limitation.
RESIN RESTORATIONS (FILLINGS)
D2330 Resin-based composite - one surface, anterior.
D2331 Resin-based composite - two surfaces, anterior.
D2332 Resin-based composite - three surfaces, anterior.
D2335 Resin-based composite - four or more surfaces or involving incisal angle (anterior).
D2391 Resin-based composite - one surface, posterior.
D2392 Resin-based composite - two surfaces, posterior.
D2393 Resin-based composite - three surfaces, posterior.
D2394 Resin-based composite - four or more surfaces, posterior.
D2410 Gold foil - one surface.
D2420 Gold foil - two surfaces.
D2430 Gold foil - three surfaces.
COMPOSITE RESTORATIONS: D2330, D2331, D2332, D2335, D2391, D2392, D2393, D2394
•Coverage is limited to 1 of any of these procedures per 6 month(s).
•D2140, D2150, D2160, D2161, D9911, also contribute(s) to this limitation.
•Porcelain and resin benefits are considered for anterior and bicuspid teeth only.
•Coverage is limited to necessary placement resulting from decay or replacement due to existing unserviceable
restorations.
TYPE 2 PROCEDURES
GOLD FOIL RESTORATIONS: D2410, D2420, D2430
•Gold foils are considered at an alternate benefit of an amalgam/composite restoration.
STAINLESS STEEL CROWN (PREFABRICATED CROWN)
D2390 Resin-based composite crown, anterior.
D2930 Prefabricated stainless steel crown - primary tooth.
D2931 Prefabricated stainless steel crown - permanent tooth.
D2932 Prefabricated resin crown.
D2933 Prefabricated stainless steel crown with resin window.
D2934 Prefabricated esthetic coated stainless steel crown - primary tooth.
STAINLESS STEEL CROWN: D2390, D2930, D2931, D2932, D2933, D2934
•Replacement is limited to 1 of any of these procedures per 12 month(s).
•Porcelain and resin benefits are considered for anterior and bicuspid teeth only.
RECEMENT
D2910 Recement inlay, onlay, or partial coverage restoration.
D2915 Recement cast or prefabricated post and core.
D2920 Recement crown.
D6930 Recement fixed partial denture.
SEDATIVE FILLING
D2940 Sedative filling.
ENDODONTICS MISCELLANEOUS
D3220 Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the
dentinocemental junction and application of medicament.
D3221 Pulpal debridement, primary and permanent teeth.
D3230 Pulpal therapy (resorbable filling)- anterior, primary tooth (excluding final
restoration).
D3240 Pulpal therapy (resorbable filling) -posterior, primary tooth (excluding final
restoration).
D3333 Internal root repair of perforation defects.
D3351 Apexification/recalcification - initial visit (apical closure/calcific repair of
perforations, root resorption, etc.)
D3352 Apexication/recalcification - interim medication replacement (apical closure/calcific
repair of perforations, root resorption, etc.).
D3353 Apexification/recalcification - final visit (includes completed root canal therapy -
apical closure/calcific repair of perforations, root resorption, etc.).
D3430 Retrograde filling - per root.
D3450 Root amputation - per root.
D3920 Hemisection (including any root removal), not including root canal therapy.
ENDODONTICS MISCELLANEOUS: D3333, D3430, D3450, D3920
•Procedure D3333 is limited to permanent teeth only.
PULPOTOMY/PULPAL DEBRIDEMENT/PULPAL THERAPY: D3220, D3221, D3230, D3240
•Procedure D3220 is limited to primary teeth.
ENDODONTIC THERAPY (ROOT CANALS)
D3310 Anterior (excluding final restoration).
D3320 Bicuspid (excluding final restoration).
D3330 Molar (excluding final restoration).
D3332 Incomplete endodontic therapy; inoperable, unrestorable or fractured tooth.
D3346 Retreatment of previous root canal therapy - anterior.
D3347 Retreatment of previous root canal therapy - bicuspid.
D3348 Retreatment of previous root canal therapy - molar.
ROOT CANALS: D3310, D3320, D3330, D3332
•Benefits are considered on permanent teeth only.
TYPE 2 PROCEDURES
•Allowances include intraoperative films and cultures but exclude final restoration.
RETREATMENT OF ROOT CANAL: D3346, D3347, D3348
•Coverage is limited to 1 of any of these procedures per 12 month(s).
•D3310, D3320, D3330, also contribute(s) to this limitation.
•Benefits are considered on permanent teeth only.
•Coverage is limited to service dates more than 12 months after root canal therapy. Allowances include intraoperative
films and cultures but exclude final restoration.
SURGICAL ENDODONTICS
D3410 Apicoectomy/periradicular surgery - anterior.
D3421 Apicoectomy/periradicular surgery - bicuspid (first root).
D3425 Apicoectomy/periradicular surgery - molar (first root).
D3426 Apicoectomy/periradicular surgery (each additional root).
SURGICAL PERIODONTICS
D4210 Gingivectomy or gingivoplasty - four or more contiguous teeth or bounded teeth
spaces per quadrant.
D4211 Gingivectomy or gingivoplasty - one to three contiguous teeth or bounded teeth spaces
per quadrant.
D4240 Gingival flap procedure, including root planing - four or more contiguous teeth or
bounded teeth spaces per quadrant.
D4241 Gingival flap procedure, including root planing - one to three contiguous teeth or
bounded teeth spaces per quadrant.
D4260 Osseous surgery (including flap entry and closure) - four or more contiguous teeth or
bounded teeth spaces per quadrant.
D4261 Osseous surgery (including flap entry and closure) - one to three contiguous teeth or
bounded teeth spaces per quadrant.
D4263 Bone replacement graft - first site in quadrant.
D4264 Bone replacement graft - each additional site in quadrant.
D4265 Biologic materials to aid in soft and osseous tissue regeneration.
D4270 Pedicle soft tissue graft procedure.
D4271 Free soft tissue graft procedure (including donor site surgery).
D4273 Subepithelial connective tissue graft procedures, per tooth.
D4274 Distal or proximal wedge procedure (when not performed in conjunction with surgical
procedures in the same anatomical area).
D4275 Soft tissue allograft.
D4276 Combined connective tissue and double pedicle graft, per tooth.
BONE GRAFTS: D4263, D4264, D4265
•Each quadrant is limited to 1 of each of these procedures per 3 year(s).
•Coverage is limited to treatment of periodontal disease.
GINGIVECTOMY: D4210, D4211
•Each quadrant is limited to 1 of each of these procedures per 3 year(s).
•Coverage is limited to treatment of periodontal disease.
OSSEOUS SURGERY: D4240, D4241, D4260, D4261
•Each quadrant is limited to 1 of each of these procedures per 3 year(s).
•Coverage is limited to treatment of periodontal disease.
TISSUE GRAFTS: D4270, D4271, D4273, D4275, D4276
•Each quadrant is limited to 2 of any of these procedures per 3 year(s).
•Coverage is limited to treatment of periodontal disease.
NON-SURGICAL PERIODONTICS
D4341 Periodontal scaling and root planing - four or more teeth per quadrant.
D4342 Periodontal scaling and root planing - one to three teeth, per quadrant.
D4381 Localized delivery of antimicrobial agents via a controlled release vehicle into
diseased crevicular tissue, per tooth, by report.
CHEMOTHERAPEUTIC AGENTS: D4381
•Each quadrant is limited to 2 of any of these procedures per 2 year(s).
•A scaling and root planing or periodontal maintenance procedure must be performed in this quadrant within 2 years
prior to the date of service for this procedure.
TYPE 2 PROCEDURES
PERIODONTAL SCALING & ROOT PLANING: D4341, D4342
•Each quadrant is limited to 1 of each of these procedures per 2 year(s).
FULL MOUTH DEBRIDEMENT
D4355 Full mouth debridement to enable comprehensive evaluation and diagnosis.
FULL MOUTH DEBRIDEMENT: D4355
•Coverage is limited to 1 of any of these procedures per 5 year(s).
PERIODONTAL MAINTENANCE
D4910 Periodontal maintenance.
PERIODONTAL MAINTENANCE: D4910
•Coverage is limited to 2 of any of these procedures per 1 benefit period.
•D1110, D1120, D1201, D1205, also contribute(s) to this limitation.
•Coverage is contingent upon evidence of full mouth active periodontal therapy. Benefits are not available if performed
on the same date as any other periodontal procedure.
DENTURE REPAIR
D5510 Repair broken complete denture base.
D5520 Replace missing or broken teeth - complete denture (each tooth).
D5610 Repair resin denture base.
D5620 Repair cast framework.
D5630 Repair or replace broken clasp.
D5640 Replace broken teeth - per tooth.
DENTURE RELINES
D5730 Reline complete maxillary denture (chairside).
D5731 Reline complete mandibular denture (chairside).
D5740 Reline maxillary partial denture (chairside).
D5741 Reline mandibular partial denture (chairside).
D5750 Reline complete maxillary denture (laboratory).
D5751 Reline complete mandibular denture (laboratory).
D5760 Reline maxillary partial denture (laboratory).
D5761 Reline mandibular partial denture (laboratory).
DENTURE RELINE: D5730, D5731, D5740, D5741, D5750, D5751, D5760, D5761
•Coverage is limited to service dates more than 6 months after placement date.
NON-SURGICAL EXTRACTIONS
D7111 Extraction, coronal remnants - deciduous tooth.
D7140 Extraction, erupted tooth or exposed root (elevation and/or forceps removal).
SURGICAL EXTRACTIONS
D7210 Surgical removal of erupted tooth requiring elevation of mucoperiosteal flap and
removal of bone and/or section of tooth.
D7220 Removal of impacted tooth - soft tissue.
D7230 Removal of impacted tooth - partially bony.
D7240 Removal of impacted tooth - completely bony.
D7241 Removal of impacted tooth - completely bony, with unusual surgical complications.
D7250 Surgical removal of residual tooth roots (cutting procedure).
OTHER ORAL SURGERY
D7260 Oroantral fistula closure.
D7261 Primary closure of a sinus perforation.
D7270 Tooth reimplantation and/or stabilization of accidentally evulsed or displaced tooth.
D7272 Tooth transplantation (includes reimplantation from one site to another and splinting
and/or stabilization).
D7280 Surgical access of an unerupted tooth.
TYPE 2 PROCEDURES
D7282 Mobilization of erupted or malpositioned tooth to aid eruption.
D7283 Placement of device to facilitate eruption of impacted tooth.
D7310 Alveoloplasty in conjunction with extractions - per quadrant.
D7311 Alveoplasty in conjunction with extractions - one to three teeth or tooth spaces, per
quadrant.
D7320 Alveoloplasty not in conjunction with extractions - per quadrant.
D7321 Alveoplasty not in conjunction with extractions - one to three teeth or tooth spaces, per
quadrant.
D7340 Vestibuloplasty - ridge extension (secondary epithelialization).
D7350 Vestibuloplasty - ridge extension (including soft tissue grafts, muscle reattachment,
revision of soft tissue attachment and management of hypertrophied and hyperplastic
tissue).
D7410 Excision of benign lesion up to 1.25 cm.
D7411 Excision of benign lesion greater than 1.25 cm.
D7412 Excision of benign lesion, complicated.
D7413 Excision of malignant lesion up to 1.25 cm.
D7414 Excision of malignant lesion greater than 1.25 cm.
D7415 Excision of malignant lesion, complicated.
D7440 Excision of malignant tumor - lesion diameter up to 1.25 cm.
D7441 Excision of malignant tumor - lesion diameter greater than 1.25 cm.
D7450 Removal of benign odontogenic cyst or tumor - lesion diameter up to 1.25 cm.
D7451 Removal of benign odontogenic cyst or tumor - lesion diameter greater than 1.25 cm.
D7460 Removal of benign nonodontogenic cyst or tumor - lesion diameter up to 1.25 cm.
D7461 Removal of benign nonodontogenic cyst or tumor - lesion diameter greater than 1.25
cm.
D7465 Destruction of lesion(s) by physical or chemical method, by report.
D7471 Removal of lateral exostosis (maxilla or mandible).
D7472 Removal of torus palatinus.
D7473 Removal of torus mandibularis.
D7485 Surgical reduction of osseous tuberosity.
D7490 Radical resection of maxilla or mandible.
D7510 Incision and drainage of abscess - intraoral soft tissue.
D7520 Incision and drainage of abscess - extraoral soft tissue.
D7530 Removal of foreign body from mucosa, skin, or subcutaneous alveolar tissue.
D7540 Removal of reaction producing foreign bodies, musculoskeletal system.
D7550 Partial ostectomy/sequestrectomy for removal of non-vital bone.
D7560 Maxillary sinusotomy for removal of tooth fragment or foreign body.
D7910 Suture of recent small wounds up to 5 cm.
D7911 Complicated suture - up to 5 cm.
D7912 Complicated suture - greater than 5 cm.
D7960 Frenulectomy (frenectomy or frenotomy) - separate procedure.
D7963 Frenuloplasty.
D7970 Excision of hyperplastic tissue - per arch.
D7972 Surgical reduction of fibrous tuberosity.
D7980 Sialolithotomy.
D7983 Closure of salivary fistula.
REMOVAL OF BONE TISSUE: D7471, D7472, D7473
•Coverage is limited to 5 of any of these procedures per 1 lifetime.
BIOPSY OF ORAL TISSUE
D7285 Biopsy of oral tissue - hard (bone, tooth).
D7286 Biopsy of oral tissue - soft.
D7287 Exfoliative cytological sample collection.
D7288 Brush biopsy - transepithelial sample collection.
TYPE 2 PROCEDURES
PALLIATIVE
D9110 Palliative (emergency) treatment of dental pain - minor procedure.
PALLIATIVE TREATMENT: D9110
•Not covered in conjunction with other procedures, except diagnostic x-ray films.
ANESTHESIA-GENERAL/IV
D9220 Deep sedation/general anesthesia - first 30 minutes.
D9221 Deep sedation/general anesthesia - each additional 15 minutes.
D9241 Intravenous conscious sedation/analgesia - first 30 minutes.
D9242 Intravenous conscious sedation/analgesia - each additional 15 minutes.
GENERAL ANESTHESIA: D9220, D9221, D9241, D9242
•Coverage is only available with a cutting procedure. Verification of the dentist's anesthesia permit and a copy of the
anesthesia report is required. A maximum of two additional units (D9221 or D9242) will be considered.
PROFESSIONAL CONSULT/VISIT/SERVICES
D9310 Consultation (diagnostic service provided by dentist or physician other than
practitioner providing treatment).
D9430 Office visit for observation (during regularly scheduled hours) - no other services
performed.
D9440 Office visit - after regularly scheduled hours.
D9930 Treatment of complications (post-surgical) - unusual circumstances, by report.
CONSULTATION: D9310
•Coverage is limited to 1 of any of these procedures per 1 provider.
OFFICE VISIT: D9430, D9440
•Procedure D9430 is allowed for accidental injury only. Procedure D9440 will be allowed on the basis of services
rendered or visit, whichever is greater.
OCCLUSAL ADJUSTMENT
D9951 Occlusal adjustment - limited.
D9952 Occlusal adjustment - complete.
OCCLUSAL ADJUSTMENT: D9951, D9952
•Coverage is considered only when performed in conjunction with periodontal procedures for the treatment of
periodontal disease.
MISCELLANEOUS
D2951 Pin retention - per tooth, in addition to restoration.
D9911 Application of desensitizing resin for cervical and/or root surfaces, per tooth.
DESENSITIZATION: D9911
•Coverage is limited to 1 of any of these procedures per 6 month(s).
•D2140, D2150, D2160, D2161, D2330, D2331, D2332, D2335, D2391, D2392, D2393, D2394, also contribute(s) to
this limitation.
•Porcelain and resin benefits are considered for anterior and bicuspid teeth only.
•Coverage is limited to necessary placement resulting from decay or replacement due to existing unserviceable
restorations.
TYPE 3 PROCEDURES
PAYMENT BASIS - PARTICIPATING PROVIDERS - Maximum Allowable Charge
BENEFIT PERIOD - Calendar Year
For Additional Limitations - See Limitations
INLAY RESTORATIONS
D2510 Inlay - metallic - one surface.
D2520 Inlay - metallic - two surfaces.
D2530 Inlay - metallic - three or more surfaces.
D2610 Inlay - porcelain/ceramic - one surface.
D2620 Inlay - porcelain/ceramic - two surfaces.
D2630 Inlay - porcelain/ceramic - three or more surfaces.
D2650 Inlay - resin-based composite - one surface.
D2651 Inlay - resin-based composite - two surfaces.
D2652 Inlay - resin-based composite - three or more surfaces.
INLAY: D2510, D2520, D2530, D2610, D2620, D2630, D2650, D2651, D2652
•Inlays will be considered at an alternate benefit of an amalgam/composite restoration and only when resulting from
caries (tooth decay) or traumatic injury.
ONLAY RESTORATIONS
D2542 Onlay - metallic - two surfaces.
D2543 Onlay - metallic - three surfaces.
D2544 Onlay - metallic - four or more surfaces.
D2642 Onlay - porcelain/ceramic - two surfaces.
D2643 Onlay - porcelain/ceramic - three surfaces.
D2644 Onlay - porcelain/ceramic - four or more surfaces.
D2662 Onlay - resin-based composite - two surfaces.
D2663 Onlay - resin-based composite - three surfaces.
D2664 Onlay - resin-based composite - four or more surfaces.
ONLAY: D2542, D2543, D2544, D2642, D2643, D2644, D2662, D2663, D2664
•Replacement is limited to 1 of any of these procedures per 5 year(s).
•D2510, D2520, D2530, D2610, D2620, D2630, D2650, D2651, D2652, D2710, D2712, D2720, D2721, D2722,
D2740, D2750, D2751, D2752, D2780, D2781, D2782, D2783, D2790, D2791, D2792, D2794, D6600, D6601,
D6602, D6603, D6604, D6605, D6606, D6607, D6608, D6609, D6610, D6611, D6612, D6613, D6614, D6615,
D6624, D6634, D6710, D6720, D6721, D6722, D6740, D6750, D6751, D6752, D6780, D6781, D6782, D6783,
D6790, D6791, D6792, D6794, also contribute(s) to this limitation.
•Frequency is waived for accidental injury.
•Porcelain and resin benefits are considered for anterior and bicuspid teeth only.
•Coverage is limited to necessary placement resulting from caries (tooth decay) or traumatic injury.
•Benefits will not be considered if procedure D2390, D2930, D2931, D2932, D2933 or D2934 has been performed
within 12 months.
CROWNS SINGLE RESTORATIONS
D2710 Crown - resin-based composite (indirect).
D2712 Crown - 3/4 resin-based composite (indirect).
D2720 Crown - resin with high noble metal.
D2721 Crown - resin with predominantly base metal.
D2722 Crown - resin with noble metal.
D2740 Crown - porcelain/ceramic substrate.
D2750 Crown - porcelain fused to high noble metal.
D2751 Crown - porcelain fused to predominantly base metal.
D2752 Crown - porcelain fused to noble metal.
D2780 Crown - 3/4 cast high noble metal.
D2781 Crown - 3/4 cast predominantly base metal.
D2782 Crown - 3/4 cast noble metal.
D2783 Crown - 3/4 porcelain/ceramic.
D2790 Crown - full cast high noble metal.
TYPE 3 PROCEDURES
D2791 Crown - full cast predominantly base metal.
D2792 Crown - full cast noble metal.
D2794 Crown - titanium.
CROWN: D2710, D2712, D2720, D2722, D2740, D2750, D2751, D2752, D2780, D2781, D2782, D2783, D2790, D2791, D2792, D2794
•Replacement is limited to 1 of any of these procedures per 5 year(s).
•D2510, D2520, D2530, D2542, D2543, D2544, D2610, D2620, D2630, D2642, D2643, D2644, D2650, D2651,
D2652, D2662, D2663, D2664, D6600, D6601, D6602, D6603, D6604, D6605, D6606, D6607, D6608, D6609,
D6610, D6611, D6612, D6613, D6614, D6615, D6624, D6634, D6710, D6720, D6721, D6722, D6740, D6750,
D6751, D6752, D6780, D6781, D6782, D6783, D6790, D6791, D6792, D6794, also contribute(s) to this limitation.
•Frequency is waived for accidental injury.
•Porcelain and resin benefits are considered for anterior and bicuspid teeth only.
•Procedures that contain titanium or high noble metal will be considered at the corresponding noble metal allowance.
•Coverage is limited to necessary placement resulting from caries (tooth decay) or traumatic injury.
•Benefits will not be considered if procedure D2390, D2930, D2931, D2932, D2933 or D2934 has been performed
within 12 months.
CORE BUILD-UP
D2950 Core buildup, including any pins.
D6973 Core build up for retainer, including any pins.
POST AND CORE
D2952 Cast post and core in addition to crown.
D2954 Prefabricated post and core in addition to crown.
FIXED CROWN AND PARTIAL DENTURE REPAIR
D2980 Crown repair, by report.
D6980 Fixed partial denture repair, by report.
CROWN LENGTHENING
D4249 Clinical crown lengthening - hard tissue.
PROSTHODONTICS - FIXED/REMOVABLE (DENTURES)
D5110 Complete denture - maxillary.
D5120 Complete denture - mandibular.
D5130 Immediate denture - maxillary.
D5140 Immediate denture - 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).
D5214 Mandibular partial denture - cast metal framework with resin denture bases (including
any conventional clasps, rests and teeth).
D5225 Maxillary partial denture - flexible base (including any clasps, rests and teeth).
D5226 Mandibular partial denture - flexible base (including any clasps, rests and teeth).
D5281 Removable unilateral partial denture - one piece cast metal (including clasps and
teeth).
D5670 Replace all teeth and acrylic on cast metal framework (maxillary).
D5671 Replace all teeth and acrylic on cast metal framework (mandibular).
D5810 Interim complete denture (maxillary).
D5811 Interim complete denture (mandibular).
D5820 Interim partial denture (maxillary).
D5821 Interim partial denture (mandibular).
D5860 Overdenture - complete, by report.
TYPE 3 PROCEDURES
D5861 Overdenture - partial, by report.
D6053 Implant/abutment supported removable denture for completely edentulous arch.
D6054 Implant/abutment supported removable denture for partially edentulous arch.
D6078 Implant/abutment supported fixed denture for completely edentulous arch.
D6079 Implant/abutment supported fixed denture for partially edentulous arch.
COMPLETE DENTURE: D5110, D5120, D5130, D5140, D5860, D6053, D6078
•Replacement is limited to 1 of any of these procedures per 5 year(s).
•Frequency is waived for accidental injury.
•Allowances include adjustments within 6 months after placement date. Procedures D5860, D6053, and D6078 are
considered at an alternate benefit of a D5110/D5120.
PARTIAL DENTURE: D5211, D5212, D5213, D5214, D5225, D5226, D5281, D5670, D5671, D5861, D6054, D6079
•Replacement is limited to 1 of any of these procedures per 5 year(s).
•Frequency is waived for accidental injury.
•Allowances include adjustments within 6 months of placement date. Procedures D5861, D6054, and D6079 are
considered at an alternate benefit of a D5213/D5214.
DENTURE ADJUSTMENTS
D5410 Adjust complete denture - maxillary.
D5411 Adjust complete denture - mandibular.
D5421 Adjust partial denture - maxillary.
D5422 Adjust partial denture - mandibular.
DENTURE ADJUSTMENT: D5410, D5411, D5421, D5422
•Coverage is limited to dates of service more than 6 months after placement date.
ADD TOOTH/CLASP TO EXISTING PARTIAL
D5650 Add tooth to existing partial denture.
D5660 Add clasp to existing partial denture.
DENTURE REBASES
D5710 Rebase complete maxillary denture.
D5711 Rebase complete mandibular denture.
D5720 Rebase maxillary partial denture.
D5721 Rebase mandibular partial denture.
TISSUE CONDITIONING
D5850 Tissue conditioning, maxillary.
D5851 Tissue conditioning, mandibular.
PROSTHODONTICS - FIXED
D6058 Abutment supported porcelain/ceramic crown.
D6059 Abutment supported porcelain fused to metal crown (high noble metal).
D6060 Abutment supported porcelain fused to metal crown (predominantly base metal).
D6061 Abutment supported porcelain fused to metal crown (noble metal).
D6062 Abutment supported cast metal crown (high noble metal).
D6063 Abutment supported cast metal crown (predominantly base metal).
D6064 Abutment supported cast metal crown (noble metal).
D6065 Implant supported porcelain/ceramic crown.
D6066 Implant supported porcelain fused to metal crown (titanium, titanium alloy, high noble
metal).
D6067 Implant supported metal crown (titanium, titanium alloy, high noble metal).
D6068 Abutment supported retainer for porcelain/ceramic FPD.
D6069 Abutment supported retainer for porcelain fused to metal FPD (high noble metal).
D6070 Abutment supported retainer for porcelain fused to metal FPD (predominantly base
metal).
D6071 Abutment supported retainer for porcelain fused to metal FPD (noble metal).
TYPE 3 PROCEDURES
D6072 Abutment supported retainer for cast metal FPD (high noble metal).
D6073 Abutment supported retainer for cast metal FPD (predominantly base metal).
D6074 Abutment supported retainer for cast metal FPD (noble metal).
D6075 Implant supported retainer for ceramic FPD.
D6076 Implant supported retainer for porcelain fused to metal FPD (titanium, titanium alloy,
or high noble metal).
D6077 Implant supported retainer for cast metal FPD (titanium, titanium alloy or high noble
metal).
D6094 Abutment supported crown - (titanium).
D6194 Abutment supported retainer crown for FPD - (titanium).
D6205 Pontic - indirect resin based composite.
D6210 Pontic - cast high noble metal.
D6211 Pontic - cast predominantly base metal.
D6212 Pontic - cast noble metal.
D6214 Pontic - titanium.
D6240 Pontic - porcelain fused to high noble metal.
D6241 Pontic - porcelain fused to predominantly base metal.
D6242 Pontic - porcelain fused to noble metal.
D6245 Pontic - porcelain/ceramic.
D6250 Pontic - resin with high noble metal.
D6251 Pontic - resin with predominantly base metal.
D6252 Pontic - resin with noble metal.
D6545 Retainer - cast metal for resin bonded fixed prosthesis.
D6548 Retainer - porcelain/ceramic for resin bonded fixed prosthesis.
D6600 Inlay - porcelain/ceramic, two surfaces.
D6601 Inlay - porcelain/ceramic, three or more surfaces.
D6602 Inlay - cast high noble metal, two surfaces.
D6603 Inlay - cast high noble metal, three or more surfaces.
D6604 Inlay - cast predominantly base metal, two surfaces.
D6605 Inlay - cast predominantly base metal, three or more surfaces.
D6606 Inlay - cast noble metal, two surfaces.
D6607 Inlay - cast noble metal, three or more surfaces.
D6608 Onlay - porcelain/ceramic, two surfaces.
D6609 Onlay - porcelain/ceramic, three or more surfaces.
D6610 Onlay - cast high noble metal, two surfaces.
D6611 Onlay - cast high noble metal, three or more surfaces.
D6612 Onlay - cast predominantly base metal, two surfaces.
D6613 Onlay - cast predominantly base metal, three or more surfaces.
D6614 Onlay - cast noble metal, two surfaces.
D6615 Onlay - cast noble metal, three or more surfaces.
D6624 Inlay - titanium.
D6634 Onlay - titanium.
D6710 Crown - indirect resin based composite.
D6720 Crown - resin with high noble metal.
D6721 Crown - resin with predominantly base metal.
D6722 Crown - resin with noble metal.
D6740 Crown - porcelain/ceramic.
D6750 Crown - porcelain fused to high noble metal.
D6751 Crown - porcelain fused to predominantly base metal.
D6752 Crown - porcelain fused to noble metal.
D6780 Crown - 3/4 cast high noble metal.
D6781 Crown - 3/4 cast predominantly base metal.
TYPE 3 PROCEDURES
D6782 Crown - 3/4 cast noble metal.
D6783 Crown - 3/4 porcelain/ceramic.
D6790 Crown - full cast high noble metal.
D6791 Crown - full cast predominantly base metal.
D6792 Crown - full cast noble metal.
D6794 Crown - titanium.
D6940 Stress breaker.
FIXED PARTIAL CROWN: D6710, D6720, D6721, D6722, D6740, D6750, D6751, D6752, D6780, D6781, D6782, D6783, D6790, D6791, D6792,
D6794
•Replacement is limited to 1 of any of these procedures per 5 year(s).
•D2510, D2520, D2530, D2542, D2543, D2544, D2610, D2620, D2630, D2642, D2643, D2644, D2650, D2651,
D2652, D2662, D2663, D2664, D2710, D2712, D2720, D2721, D2722, D2740, D2750, D2751, D2752, D2780,
D2781, D2782, D2783, D2790, D2791, D2792, D2794, D6600, D6601, D6602, D6603, D6604, D6605, D6606,
D6607, D6608, D6609, D6610, D6611, D6612, D6613, D6614, D6615, D6624, D6634, also contribute(s) to this
limitation.
•Frequency is waived for accidental injury.
•Porcelain and resin benefits are considered for anterior and bicuspid teeth only.
•Procedures that contain titanium or high noble metal will be considered at the corresponding noble metal allowance.
•Benefits will not be considered if procedure D2390, D2930, D2931, D2932, D2933 or D2934 has been performed
within 12 months.
FIXED PARTIAL INLAY: D6600, D6601, D6602, D6603, D6604, D6605, D6606, D6607, D6624
•Replacement is limited to 1 of any of these procedures per 5 year(s).
•D2510, D2520, D2530, D2542, D2543, D2544, D2610, D2620, D2630, D2642, D2643, D2644, D2650, D2651,
D2652, D2662, D2663, D2664, D2710, D2712, D2720, D2721, D2722, D2740, D2750, D2751, D2752, D2780,
D2781, D2782, D2783, D2790, D2791, D2792, D2794, D6608, D6609, D6610, D6611, D6612, D6613, D6614,
D6615, D6634, D6710, D6720, D6721, D6722, D6740, D6750, D6751, D6752, D6780, D6781, D6782, D6783,
D6790, D6791, D6792, D6794, also contribute(s) to this limitation.
•Frequency is waived for accidental injury.
•Porcelain and resin benefits are considered for anterior and bicuspid teeth only.
•Procedures that contain titanium or high noble metal will be considered at the corresponding noble metal allowance.
•Benefits will not be considered if procedure D2390, D2930, D2931, D2932, D2933 or D2934 has been performed
within 12 months.
FIXED PARTIAL ONLAY: D6608, D6609, D6610, D6611, D6612, D6613, D6614, D6615, D6634
•Replacement is limited to 1 of any of these procedures per 5 year(s).
•D2510, D2520, D2530, D2542, D2543, D2544, D2610, D2620, D2630, D2642, D2643, D2644, D2650, D2651,
D2652, D2662, D2663, D2664, D2710, D2712, D2720, D2721, D2722, D2740, D2750, D2751, D2752, D2780,
D2781, D2782, D2783, D2790, D2791, D2792, D2794, D6600, D6601, D6602, D6603, D6604, D6605, D6606,
D6607, D6624, D6710, D6720, D6721, D6722, D6740, D6750, D6751, D6752, D6780, D6781, D6782, D6783,
D6790, D6791, D6792, D6794, also contribute(s) to this limitation.
•Frequency is waived for accidental injury.
•Porcelain and resin benefits are considered for anterior and bicuspid teeth only.
•Procedures that contain titanium or high noble metal will be considered at the corresponding noble metal allowance.
•Benefits will not be considered if procedure D2390, D2930, D2931, D2932, D2933 or D2934 has been performed
within 12 months.
FIXED PARTIAL PONTIC: D6205, D6210, D6211, D6212, D6214, D6240, D6241, D6242, D6245, D6250, D6251, D6252
•Replacement is limited to 1 of any of these procedures per 5 year(s).
•D5211, D5212, D5213, D5214, D5225, D5226, D5281, D6058, D6059, D6060, D6061, D6062, D6063, D6064,
D6065, D6066, D6067, D6068, D6069, D6070, D6071, D6072, D6073, D6074, D6075, D6076, D6077, D6094,
D6194, also contribute(s) to this limitation.
•Frequency is waived for accidental injury.
•Porcelain and resin benefits are considered for anterior and bicuspid teeth only.
•Procedures that contain titanium or high noble metal will be considered at the corresponding noble metal allowance.
IMPLANT SUPPORTED CROWN: D6058, D6059, D6060, D6061, D6062, D6063, D6064, D6065, D6066, D6067, D6094
•Replacement is limited to 1 of any of these procedures per 5 year(s).
•D5211, D5212, D5213, D5214, D5225, D5226, D5281, D6194, D6205, D6210, D6211, D6212, D6214, D6240,
D6241, D6242, D6245, D6250, D6251, D6252, also contribute(s) to this limitation.
•Frequency is waived for accidental injury.
•Porcelain and resin benefits are considered for anterior and bicuspid teeth only.
•Procedures that contain titanium or high noble metal will be considered at the corresponding noble metal allowance.
IMPLANT SUPPORTED RETAINER: D6068, D6069, D6070, D6071, D6072, D6073, D6074, D6075, D6076, D6077, D6194
•Replacement is limited to 1 of any of these procedures per 5 year(s).
•D5211, D5212, D5213, D5214, D5225, D5226, D5281, D6058, D6059, D6060, D6061, D6062, D6063, D6064,
D6065, D6066, D6067, D6094, D6205, D6210, D6211, D6212, D6214, D6240, D6241, D6242, D6245, D6250,
D6251, D6252, also contribute(s) to this limitation.
•Frequency is waived for accidental injury.
•Porcelain and resin benefits are considered for anterior and bicuspid teeth only.
•Procedures that contain titanium or high noble metal will be considered at the corresponding noble metal allowance.
TYPE 3 PROCEDURES
CAST POST AND CORE FOR PARTIALS
D6970 Cast post and core in addition to fixed partial denture retainer.
D6971 Cast post as part of fixed partial denture retainer.
D6972 Prefabricated post and core in addition to fixed partial denture retainer.
9260 Takeover Ed. 01-05
ORTHODONTIC EXPENSE BENEFITS
We will determine orthodontic expense benefits according to the terms of the group policy for orthodontic
expenses incurred by an Insured.
DETERMINING BENEFITS.The benefits payable will be determined by totaling all of the Covered Expenses
submitted. This amount is reduced by the Deductible, if any. The result is then multiplied by the Coinsurance
Percentage shown in the Schedule of Benefits. Benefits are subject to the Maximum Amount shown in the
Schedule of Benefits.
DEDUCTIBLE.The Deductible is shown on the Schedule of Benefits and is a specified amount of Covered
Expenses that must be incurred and paid by each Insured person prior to any benefits being paid.
MAXIMUM AMOUNT.The Maximum Benefit During Lifetime shown in the Schedule of Benefits is the
maximum amount that may be paid for the Covered Expenses incurred by an Insured during his or her lifetime.
COVERED EXPENSES.Covered Expenses refer to the usual and customary charges made by a provider for
necessary orthodontic treatment rendered while the person is insured under this section. Expenses are limited to
the Maximum Amount shown in the Schedule of Benefits and Limitations.
Usual and Customary (“U&C”) describes those dental charges that we have determined to be the usual and
customary charge for a given dental procedure within a particular ZIP code area. The U&C is based upon a
combination of dental charge information taken from our own database as well as from data received from
nationally recognized industry databases. From the array of charges ranked by amount, your Policyholder (in
most cases your employer) has selected a percentile that will be used to determine the maximum U&C for your
plan. The U&C is reviewed and updated periodically. The U&C can differ from the actual fee charged by your
provider and is not indicative of the appropriateness of the provider’s fee. Instead, the U&C is simply a plan
provision used to determine the extent of benefit coverage purchased by your Policyholder.
ORTHODONTIC TREATMENT.Orthodontic Treatment refers to the movement of teeth by means of active
appliances to correct the position of maloccluded or malpositioned teeth.
TREATMENT PROGRAM.Treatment Program ("Program") means an interdependent series of orthodontic
services prescribed by a provider to correct a specific dental condition. A Program will start when the active
appliances are inserted. A Program will end when the services are done, or after eight calendar quarters starting
with the day the appliances were inserted, whichever is earlier.
EXPENSES INCURRED.Benefits will be payable when a Covered Expense is incurred:
a. at the end of every quarter (three-month period) of a Program for an Insured who pursues a
Program, but not beyond the date the Program ends; or
b. at the time the service is rendered for an Insured who incurs Covered Expenses but does not pursue
aProgram.
The Covered Expenses for a Program are based on the estimated cost of the Insured's Program. They are pro-
rated by quarter (three-month periods) over the estimated length of the Program, up to a maximum of eight
quarters. The last quarterly payment for a Program may be changed if the estimated and actual cost of the
Program differ.
BENEFITS PAYABLE UPON TERMINATION.If coverage terminates during a Program quarter, the
quarterly benefit payable for that quarter will be pro-rated by day for the period of time that coverage was in-force
and premium was received.
LIMITATIONS.Covered Expenses will not include and benefits will not be payable for expenses incurred:
1. for a Program begun before the Insured became covered under this section, unless the Insured was
covered for Orthodontic Expense Benefits under the prior carrier on August 31, 2006 and are both:
a. insured under this policy; and
b. currently undergoing a Treatment Program on September 1, 2006.
2. in the first 12 months that a person is insured if the person is a Late Entrant.
3. before the Insured has been insured under this section for at least 12 consecutive months unless the
Insured is covered on September 1, 2006.
4. in any quarter of a Program if the Insured was not covered under this section for the entire quarter.
5. if the Insured's insurance under this section terminates.
6. for which the Insured is entitled to benefits under any workmen’s compensation or similar law, or for
charges for services or supplies received as a result of any dental condition caused or contributed to by
an injury or sickness arising out of or in the course of any employment for wage or profit.
7. for charges the Insured is not legally required to pay or would not have been made had no insurance
been in force.
8. for services not required for necessary care and treatment or not within the generally accepted
parameters of care.
9. because of war or any act of war, declared or not.
10. To replace lost or stolen appliances.
9300 Ed. 01-05
COORDINATION OF BENEFITS
This section applies if an Insured person has dental coverage under more than one Plan definition below. All
benefits provided under this policy are subject to this section.
EFFECT ON BENEFITS.The Order of Benefit Determination rules below determine which Plan will pay as
the primary Plan. If all or any part of an Allowable Expense under this Plan is an Allowable Expense under any
other Plan, then benefits will be reduced so that, when they are added to benefits payable under any other Plan for
the same service or supply, the total does not exceed 100% of the total Allowable Expense.
If another Plan is primary and this Plan is considered secondary, the amount by which benefits have been reduced
during the Claim Determination Period will be used by us to pay the Allowable Expenses not otherwise paid
which were incurred by you in the same Claim Determination Period. We will determine our obligation to pay
for Allowable Expenses as each claim is submitted, based on all claims submitted in the current Claim
Determination Period.
DEFINITIONS.The following apply only to this provision of the policy.
1. “Plan” refers to the group policy and any of the following plans, whether insured or uninsured, providing
benefits for dental services or supplies:
a. Any group or blanket insurance policy.
b. Any group Blue Cross, group Blue Shield, or group prepayment arrangement.
c. Any labor/management, trusteed plan, labor organization, employer organization, or employee
organization plan, whether on an insured or uninsured basis.
d. Any coverage under a governmental plan that allows coordination of benefits, or any coverage
required or provided by law. This does not include a state plan under Medicaid (TitleXVIII and
XIX of the Social Security Act as enacted or amended). It also does not include any plan whose
benefits by law are excess to those of any private insurance program or other non-governmental
program.
2. “Plan” does not include the following:
a. Individual or family benefits provided through insurance contracts, subscriber contracts, coverage
through individual HMOs or other prepayment arrangements.
b. Coverages for school type accidents only, including athletic injuries.
3. “Allowable Expense” refers to any necessary, reasonable and customary item of expense at least a portion
of which is covered under at least one of the Plans covering the Insured person for whom that claim is
made. When a Plan provides services rather than cash payments, the reasonable cash value of each
service will be both an Allowable Expense and a benefit paid. Benefits payable under another Plan
include benefits that would have been payable had a claim been made for them.
4. “Claim Determination Period” refers to a Benefit Period, but does not include any time during which a
person has no coverage under this Plan.
5. “Custodial Parent” refers to a parent awarded custody of a minor child by a court decree. In the absence
of a court decree, it is the parent with whom the child resides more than half of the calendar year without
regard to any temporary visitation.
ORDER OF BENEFIT DETERMINATION.When two or more Plans pay benefits, the rules for determining
the order of payment are as follows:
1. A Plan that does not have a coordination of benefits provision is always considered primary and will pay
benefits first.
2. If a Plan also has a coordination of benefits provision, the first of the following rules that describe which
Plan pays its benefits before another Plan is the rule to use:
a. The benefits of a Plan that covers a person as an employee, member or subscriber are determined
before those of a Plan that covers the person as a dependent.
b. If a Dependent child is covered by more than one Plan, then the primary Plan is the Plan of the
parent whose birthday is earlier in the year if:
i. the parents are married;
ii. the parents are not separated (whether or not they ever have been married); or
iii. a court decree awards joint custody without specifying that one party has the
responsibility to provide dental coverage.
If both parents have the same birthday, the Plan that covered either of the parents longer is
primary.
c. If the Dependent child is covered by divorced or separated parents under two or more Plans,
benefits for that Dependent child will be determined in the following order:
i. the Plan of the Custodial Parent;
ii. the Plan of the spouse of the Custodial Parent;
iii. the Plan of the non-Custodial Parent; and then
iv. the Plan of the spouse of the non-Custodial Parent.
However, if the specific terms of a court decree establish a parent’s responsibility for the
child’s dental expenses and the Plan of that parent has actual knowledge of those terms, that
Plan is primary. This rule applies to Claim Determination Periods or Benefit Periods
commencing after the Plan is given notice of the court decree.
d. The benefits of a Plan that cover a person as an employee who is neither laid-off nor retired (or as
that employee’s dependent) are determined before those of a Plan that covers that person as a
laid-off or retired employee (or as that employee’s dependent). If the other Plan does not have
this rule, and if, as a result, the Plans do not agree on the order of benefits, this rule will be
ignored.
e. If a person whose coverage is provided under a right of continuation provided by a federal or
state law also is covered under another Plan, the Plan covering the person as an employee,
member, subscriber or retiree (or as that person’s dependent) is primary, and the continuation
coverage is secondary. If the other Plan does not have this rule, and if, as a result, the Plans do
not agree on the order of benefits, this rule will be ignored.
f. The benefits of a Plan that has covered a person for a longer period will be determined first.
If the preceding rules do not determine the primary Plan, the allowable expenses shall be shared equally between
the Plans meeting the definition of Plan under this provision. In addition, this Plan will not pay more than what it
would have paid had it been primary.
RIGHT TO RECEIVE AND RELEASE NECESSARY INFORMATION.We may without your consent and
notice to you:
1. Release any information with respect to your coverage and benefits under the policy; and
2. Obtain from any other insurance company, organization or person any information with respect to your
coverage and benefits under another Plan.
You must provide us with any information necessary to coordinate benefits.
FACILITY OF PAYMENT.When other Plans make payments that should have been made under this Plan
according to the above terms, we will, at our discretion, pay to any organizations making these payments any
amounts that we decide will satisfy the intent of the above terms. Amounts paid in this way will be benefits paid
under this Plan. We will not be liable to the extent of these payments.
RIGHT OF RECOVERY.When we make payments for Allowable Expenses in excess of the amount that will
satisfy the intent of the above terms, we will recover these payments, to the extent of the excess, from any persons
or organizations to or for whom these payments were made. The amount of the payments made includes the
reasonable cash value of any benefits provided in the form of services.
9310 Ed. 01-05
GENERAL PROVISIONS
NOTICE OF CLAIM.Written notice of a claim must be given to us within 30 days after the incurred date of the
services provided for which benefits are payable.
Notice must be given to us at our Home Office, or to one of our agents. Notice should include the Policyholder's
name, Insured's name, and policy number. If it was not reasonably possible to give written notice within the 30
day period stated above, we will not reduce or deny a claim for this reason if notice is filed as soon as is
reasonably possible.
CLAIM FORMS.When we receive the notice of a claim, we will send the claimant forms for filing proof of
loss. If these forms are not furnished within 15 days after the giving of such notice, the claimant will meet our
proof of loss requirements by giving us a written statement of the nature and extent of loss within the time limit
for filing proofs of loss.
PROOF OF LOSS.Writtenproofoflossmustbegiventouswithin90daysaftertheincurreddateofthe
services provided for which benefits are payable. If it is impossible to give written proof within the 90-day
period, we will not reduce or deny a claim for this reason if the proof is filed as soon as is reasonably possible.
TIME OF PAYMENT.We will pay all benefits immediately when we receive due proof. Any balance
remaining unpaid at the end of any period for which we are liable will be paid at that time.
PAYMENT OF BENEFITS.AllbenefitswillbepaidtotheInsuredunlessyouauthorizeusinwritingtomake
payment to the Provider providing the services or supplies.
FACILITY OF PAYMENT.If an Insured or beneficiary is not capable of giving us a valid receipt for any
payment or if benefits are payable to the estate of the Insured, then we may, at our option, pay the benefit up to an
amount not to exceed $5,000, to any relative by blood or connection by marriage of the Insured who is considered
by us to be equitably entitled to the benefit.
Any equitable payment made in good faith will release us from liability to the extent of payment.
PROVIDER-PATIENT RELATIONSHIP.The Insured may choose any Provider who is licensed by the law
of the state in which treatment is provided within the scope of their license. We will in no way disturb the
provider-patient relationship.
LEGAL PROCEEDINGS.No legal action can be brought against us until 60 days after the Insured sends us the
required proof of loss. No legal action against us can start more than five years after proof of loss is required.
INCONTESTABILITY.Any statement made by the Policyholder to obtain the Policy is a representation and
not a warranty. No misrepresentation by the Policyholder will be used to deny a claim or to deny the validity of
the Policy unless:
1. The Policy would not have been issued if we had known the truth; and
2. We have given the Policyholder a copy of a written instrument signed by the Policyholder that contains
the misrepresentation.
The validity of the Policy will not be contested after it has been in force for one year, except for nonpayment of
premiums or fraudulent misrepresentations.
WORKER’S COMPENSATION.The coverage provided under the Policy is not a substitute for coverage
under a workmen’s compensation or state disability income benefit law and does not relieve the Policyholder of
any obligation to provide such coverage.
9323 Ed. 01-05
GENERAL PROVISIONS (CONTINUED)
CONFORMITY WITH LAW.Any policy provision that conflicts with the laws of the state in which the policy
is issued, when the policy is issued, is automatically changed to meet the minimum requirements of those laws.
ENTIRE CONTRACT.The policy and the application of the Policyholder constitute the entire contract
between the parties. A copy of the Policyholder’s application is attached to the policy when issued. All
statements made by the Policyholder or an Insured will, in the absence of fraud, be considered representations and
not warranties. No statement made to obtain insurance will be used to avoid the insurance or reduce the benefits
of this policy unless it is in a written application signed by the Policyholder or Insured. A copy of this must have
been given to the Policyholder or Insured.
No change in this policy will be valid unless approved in writing by one of our officers and given to the
Policyholder for attachment to the policy. No agent has the authority to change this policy or waive any of its
provisions. Any change in this policy will be valid even though an Insured may not have agreed to it.
INSURANCE DATA.The Policyholder will furnish, at our request, data necessary to administer this policy.
The data will include, but not be limited to data:
i. necessary to calculate premiums;
ii. necessary to determine a person's effective date or termination date of insurance;
iii. necessary to determine the proper coverage level of insurance.
We shall have the right to inspect any of the Policyholder's records we find necessary to properly administer this
policy. Any inspections will be at a time and place convenient to the Policyholder.
We will not refuse to insure a person who is eligible to be insured just because the Policyholder fails or errs in
giving us the data necessary to include that person for coverage. An Insured's insurance will not stay in force nor
an amount of insurance be continued after the termination date, according to the Conditions for Insurance,
because the Policyholder fails or errors in giving us the necessary data concerning an Insured's termination.
CERTIFICATES.We will issue certificates to the Policyholder showing the coverage under the policy. The
Policyholder will distribute a certificate to each insured Member. If the terms of the certificate differ from the
policy, the terms stated in the policy will govern.
PARTICIPATION REQUIREMENTS.There are two requirements that must be met in order for the policy to
be placed in force, and to remain in force:
a. a certain percentage of all Members qualified for insurance must be insured at all times; and
b. a certain number of Insureds must be insured at all times.
The Participation Requirements are as follows:
Percentage of Members- 100% Participation in another
dental plan will be considered as
participation in this policy.
Number of Members- 10
TERMINATION OF THE POLICY.The Policyholder may terminate this policy as of any Premium Due Date
by giving us written notice before that date.
We may terminate this policy on the earlier of:
1. any Premium Due Date if the participation of Insureds and/or Dependents does not meet the requirements
in "Conditions For Insurance." Written notice of termination of insurance must be given to the
Policyholder at least 45 days before the date of termination.
2. any Premium Due Date on or after the first policy year, for reasons other than lack of participation.
Written notice of termination of insurance must be given to the Policyholder at least 60 days before the
date of termination.
If any premium is not paid when due, this policy will automatically be terminated as of the Premium Due Date,
except as stated below.
GRACE PERIOD.This policy has a 31 day grace period. This means that if a renewal premium is not paid on
or before the date it is due, it may be paid during the following 31 days. During the grace period, the policy will
stay in force. If the Policyholder has not sent us a written request to terminate the policy and a premium is not
paid by the end of the grace period, the policy will terminate at the end of the grace period. If the Policyholder
gives us written notice of termination before the Premium Due Date, the policy will be terminated as of the date
requested. The Policyholder will be liable for any unpaid premium for the time this policy was in force, including
the grace period.
CONSIDERATION.This policy is issued to the Policyholder in consideration of the application and the
payment of premiums specified in this policy.
TERMS AND CONDITIONS.Payment of any benefit under this policy is subject to the definitions and all
other terms of this policy pertinent to the benefit.
Claims Review Procedures
CLAIMS REVIEW PROCEDURES
AS REQUIRED UNDER
EMPLOYEE RETIREMENT INCOME SECURITY ACT OF 1974 (ERISA)
The following provides information regarding the claims review process and your rights to request a review of
any part of a claim that is denied. Please note that certain state laws may also require specified claims payment
procedures as well as internal appeal procedures and/or independent external review processes. Therefore, in
addition to the review procedures defined below, you may also have additional rights provided to you under state
law. If your state has specific grievance procedures, an additional notice specific to your state will also be
included within the group policy and your certificate.
CLAIMS FOR BENEFITS
Claims may be submitted by mailing the completed claim form along with any requested information to:
Ameritas Life Insurance Corp.
PO Box 82520
Lincoln, NE 68501
NOTICE OF DECISION OF CLAIM
We will evaluate your claim promptly after we receive it. We will provide you written notice regarding the
payment under the claim within at least 30 calendar days following receipt of the claim. This period may be
extended for an additional 15 days, provided that we have determined that an extension is necessary due to
matters beyond our control, and notify you, prior to the expiration of the initial 30-day period, of the
circumstances requiring the extension of time and the date by which we expect to render a decision. If the
extension is due to your failure to provide information necessary to decide the claim, the notice of extension shall
specifically describe the required information we need to decide the claim.
If we request additional information, you will have 45 days to provide the information. If you do not provide the
requested information within 45 days, we may decide your claim based on the information we have received.
If we deny any part of your claim, you will receive a written notice of denial containing:
a. The reasons for our decision.
b. Reference to the parts of the Group Policy on which our decision is based.
c. Reference to any internal rule or guideline relied upon in making our decision, along with your right to
receive a copy of these guidelines, free of charge, upon request.
d. A statement that you may request an explanation of the scientific or clinical judgment we relied upon to
exclude expenses that are experimental or investigational, or are not necessary or accepted according to
generally accepted standards of dental practice.
e. A description of any additional information needed to support your claim and why such information is
necessary.
f. Information concerning your right to a review of our decision.
g. Information concerning your right to bring a civil action for benefits under section 502(a) of ERISA
following an adverse benefit determination on review.
REVIEW PROCEDURE
If all or part of a claim is denied, you may request a review. You must request a review in writing within 180
days after receiving notice of the denial.
You may send us written comments or other items to support your claim. You may review and receive copies of
any non-privileged information that is relevant to your request for review. There will be no charge for such
copies. You may request the names of the experts we consulted who provided advice to us about your claim.
The review will be conducted by the Plan’s named fiduciary and will be someone other than the person who
denied the initial claim and will not be subordinate to that person. The person conducting the review will not give
deference to the initial denial decision. If the denial was based in whole or in part on a medical judgment,
including determinations with regard to whether a service was considered experimental, investigational, and/or
not medically necessary, the person conducting the review will consult with a qualified health care professional.
This health care professional will be someone other than the person who made the original judgment and will not
be subordinate to that person. Our review will include any written comments or other items you submit to support
your claim.
We will review your claim promptly after we receive your request. Within at least 60 days after we receive your
request for review we will send you a written decision on review.
If we deny any part of your claim on review, you will receive a written notice of denial containing:
a. The reasons for our decision.
b. Reference to the parts of the Group Policy on which our decision is based.
c. Reference to any internal rule or guideline relied upon in making our decision along with your right to
receive a copy of these guidelines, free of charge, upon request.
d. Information concerning your right to receive, free of charge, copies of non-privileged documents and
records relevant to your claim.
e. A statement that you may request an explanation of the scientific or clinical judgement we relied upon to
exclude expenses that are experimental or investigational, or are not necessary or accepted according to
generally accepted standards of dental practice.
f. Information concerning your right to bring a civil action for benefits under section 502(a) of ERISA.
Certain state laws also require specified internal appeal procedures and/or external review processes. In addition
to the review procedures defined above, you may also have additional rights provided to you under state law.
Please contact your state insurance regulatory agency for assistance. In any event, you need not exhaust such
state law procedures prior to bringing civil action under Section 502(a) of ERISA.
Any request for claim review should be sent to:
Quality Control, P.O. Box 82629, Lincoln, NE 68501-2629.
FDL1-504-999
FORT DEARBORN LIFE INSURANCE COMPANY
(A stock life insurance company herein called “We,” “Us,” “Our”)
Chicago, Illinois
Administrative Office:
2400 Lakeside Blvd., Richardson, TX. 75082.7399
Issues this Group Insurance Policy to:
POLICYHOLDER NAME: CDG AUTOMOTIVE, LLC
GROUP POLICY NUMBER: GAZ______3098-0001
EFFECTIVE DATE: 07/01/2006
INITIAL PREMIUM RATES: See attached Rate Addendum
This Policy is delivered in the State of Arizona and is subject to the laws of that jurisdiction.
This Policy is issued in consideration of the Application of the Policyholder, a copy of which is attached, and of the
payment of premiums by the Policyholder when due. We will pay benefits under the terms of this Policy in
accordance with its provisions.
The first anniversary occurs on 02/01/2008 and all future anniversaries in twelve month intervals.
IN WITNESS WHEREOF, Fort Dearborn Life Insurance Company has caused this Policy to be executed at its
home office in Chicago, Illinois.
President Secretary
THIS IS A LEGAL CONTRACT BETWEEN THE POLICYHOLDER AND FORT DEARBORN
PLEASE READ CAREFULLY
NON-PARTICIPATING
GROUP TERM LIFE INSURANCE POLICY
AD&D Benefits
FDL1-504-999 1
TABLE OF CONTENTS
Application (Copy Attached)
Definitions
Eligibility and Effective Dates
Group Term Life Insurance Benefit
Conversion of Life Insurance
Waiver of Premium
Accelerated Death - Terminal Illness Benefit
Accidental Death, Dismemberment and Loss of Sight Benefit
Premium Provisions
Termination Provisions
General Provisions
FDL1-504-999 2
DEFINITIONS
This section tells You the meaning of special words and phrases used in this Policy. To help You recognize
these special words and phrases, the first letter of each word, or each word in the phrase, is capitalized
wherever it appears.
Accident or Accidental means a sudden, unexpected event that was not reasonably foreseeable.
Actively at Work or Active Work means that an Employee is:
1. performing the normal duties of his occupation; and
2. working the number of hours set forth in the Application.
Application means the document which sets forth the eligible classes, the amounts of insurance, and other relevant
information pertaining to the plan of insurance for which the Policyholder applied. The Application is attached to
and forms a part of this Policy, and shall include any subsequent amendments to the Application.
Base Annual Salary means the gross annual compensation prior to before-tax payroll deductions, if any, which an
Insured earns from his occupation with the Policyholder.
It does not include Salary from overtime, bonuses or any other form of extra pay. However, if an Employee’s Salary
is based in whole or in part on commissions, Base Annual Salary will include the amount paid in commissions
during the preceding twelve-month calendar period. An Employee’s deferred contributions to a 401K plan or salary
reduction contributions to a cafeteria plan which are maintained by the Policyholder will not be deducted when
calculating gross annual compensation.
Increases to Base Annual Salary which result in a benefit increase of $50,000 or greater and are above the guarantee
issue amount will be subject to evidence of insurability satisfactory to Us before the increased benefit can become
effective. Receipt of premium before we have approved any evidence of insurability will not constitute acceptance
and does not guarantee issuance of any benefit amount prior to our approval.
Basic Weekly Wage means the gross weekly compensation prior to before-tax payroll deductions, if any, which an
Insured earns from his occupation with the Policyholder.
It does not include compensation from overtime, bonuses or any other form of extra pay. However, if an
Employee’s compensation is based in whole or in part on commissions, Basic Weekly Wage will include the weekly
average paid in commissions during the preceding twelve-month calendar period. An Employee’s deferred
contributions to a 401K plan or salary reduction contributions to a cafeteria plan which are maintained by the
Policyholder will not be deducted when calculating gross weekly compensation.
Base Annual Salary/Basic Weekly Wage for each Insured who is a partner means the Insured’s annual/average
weekly compensation from the partnership during the calendar year prior to the date of the Insured’s loss, as reported
on the partnership federal income tax return as the "net Salary (loss) from self-employment" for that year.
If an Insured was not a partner during the calendar year prior to the date of loss, Base Annual Salary/Basic Weekly
Wage means the Insured’s annual/average weekly compensation (excluding dividends, capital gains, and return of
capital) from the partnership prior to the date of the Insured’s loss, determined in accordance with the terms of the
applicable partnership agreement. In the event of a disagreement between Us and the claimant, an adjustment will
be made, if warranted, after the Insured’s subsequent federal income tax return is submitted to Us.
No benefits are payable when any of the above calculations result in an amount less than zero.
FDL1-504-999 3
Base Annual Salary/Basic Weekly Wage for each Insured who is a sole proprietor or shareholder in a Subchapter
S Corporation or a member in a limited liability company means the Insured’s annual/average weekly net taxable
income (excluding dividends, capital gains, and return of capital) derived from the Policyholder for the calendar
year prior to the date of the Insured’s loss, as reported on his federal income tax return. The Insured’s
annual/average weekly net taxable income equals A minus B, where:
A = The Insured’s annual/average weekly taxable income derived from the Policyholder for the prior calendar
year (excluding dividends, capital gains, and return of capital), as reported on the Insured’s federal income
tax return; and
B = The Insured’s annual/average weekly deductible work expenses attributable to his work for the Policyholder
during the prior calendar year, as reported on the Insured’s federal income tax return.
If an Insured was not a sole proprietor or shareholder in a Subchapter S corporation or a member in a Limited
Liability Company during the calendar year prior to the date of the Insured’s loss, Base Annual Salary/Basic Weekly
Wage means an Insured’s annual/average weekly net taxable income derived from the Policyholder for the period he
was a sole proprietor or shareholder in a Subchapter S corporation or a member in a Limited Liability Company
prior to the date of the Insured’s loss. The Insured’s annual/average weekly net taxable income will be based on the
taxable income derived from the Policyholder for the period of the Insured’s work as a sole proprietor or shareholder
in a Subchapter S corporation or a member in a Limited Liability Company for the Policyholder, taking into account
his deductible work expenses attributable to his work for the Policyholder during the same period.
No benefits are payable when any of the above calculations result in an amount less than zero.
Contributory means the Insureds pay a portion of the premium for this insurance coverage.
Employee means an Actively at Work full-time employee whose principal employment is with the Employer, at the
Employer’s usual place of business or such place(s) that the Employer’s normal course of business may require, who
is Actively at Work for the minimum hours per week as stated in the Application and is reported on the Employer’s
records for Social Security and withholding tax purposes.
Injury means bodily injury resulting directly from an Accident and independently of all other causes.
Insured means an Employee covered under this Policy.
Male Pronoun whenever used includes the female.
Noncontributory means the Policyholder pays 100% of the premium for this insurance.
FDL1-504-999 4
Policy means this contract between the Policyholder and Us including the attached Application, which provides
group insurance benefits.
Policyholder means the person, firm, or institution named on the face of this Policy.
Proof under the Accelerated Death Benefit means evidence satisfactory to Us that an Insured is Terminally Ill. We
reserve the right to determine, at our sole discretion, if Proof is acceptable.
Terminally Ill under the Accelerated Death Benefit means an Insured has a life expectancy of 12 months or less,
due to a medical condition.
Total Disability or Totally Disabled under the Waiver of Premium provision means an Insured is completely
unable to engage in any occupation for wage or profit because of Sickness or Injury.
FDL1-504-999 5
ELIGIBILITY AND EFFECTIVE DATE PROVISIONS
ELIGIBILITY
All Employees who belong to an eligible class and work the minimum number of hours as set forth in the
Application are eligible for group insurance. An Employee must be Actively at Work for his insurance coverage to
become effective.
EMPLOYEE EFFECTIVE DATE OF COVERAGE
(Noncontributory Benefits)
An Employee who is Actively at Work will become insured for Noncontributory benefits under this Policy on the
day following completion of the Employee waiting period, if any, set forth in the Application.
If an Employee waives all or a portion of his Noncontributory coverage and chooses to enroll at a later date, the
Employee is considered a late applicant and must furnish evidence of insurability satisfactory to Us before coverage
can become effective. Coverage will become effective on the date We determine that the evidence is satisfactory
and We provide written notice of approval.
EMPLOYEE EFFECTIVE DATE OF COVERAGE
(Contributory Benefits)
An Employee may apply for Contributory insurance coverage at any time. His coverage will become effective as
follows, provided he is Actively at Work on that date:
1. If the enrollment form is signed on or before the end of the waiting period, if any, as stated in the Application,
the coverage will become effective on the day following completion of the waiting period.
2. If the enrollment form is signed after the end of the waiting period, but within 31 days after that day, the
coverage will become effective the date the Employee signs the enrollment form.
3. If the enrollment form is signed following this 31-day period, the Employee is considered a late applicant and
must furnish evidence of insurability satisfactory to Us before coverage can become effective. Coverage will
become effective on the date We determine that the evidence is satisfactory and We provide written notice of
approval.
DEFERRED EFFECTIVE DATE
An Employee must be Actively at Work on the date his initial coverage or any increases in coverage are scheduled
to begin. If:
1. he is absent from Active Work on the date such coverage would otherwise become effective; and
2. his absence is caused by an injury, illness or layoff,
the effective date of any initial coverage or increased coverage will be deferred until the first day he returns to
Active Work. An Employee will be considered Actively at Work if he was actually at work on the day immediately
preceding:
1. a weekend (except for one or both of these days if they are scheduled work days);
2. a holiday (except when such holiday is a scheduled work day);
3. a paid vacation;
4. any nonscheduled work day.
FDL1-504-999 6
EFFECTIVE DATE IF WE REQUIRE EVIDENCE OF INSURABILITY
If an Employee is required to submit evidence of insurability satisfactory to Fort Dearborn Life Insurance Company,
insurance in the amount for which We require such evidence will become effective on the date We determine that
the evidence is satisfactory and We provide written notice of approval.
EFFECTIVE DATE OF CHANGES IN AMOUNT OF BENEFIT
Any change in the amount of an Insured’s benefits caused by a change in class, change in salary, age reduction or
amendment to the Policy will become effective on the effective date of the change. If the change results in an
increase in the amount of insurance, the Insured must be Actively at Work on that date. If the Insured is not
Actively at Work, the increase will take effect on the day he is again Actively at Work.
ELIGIBILITY AFTER TERMINATION OF EMPLOYMENT
If an Employee’s coverage ends due to termination of employment he must meet all the requirements of a new
Employee if he is rehired at a later date.
FDL1-504-999 7
GROUP TERM LIFE INSURANCE BENEFIT
BENEFIT
We will pay an Insured’s beneficiary the amount of life insurance in force as of the date of the Insured’s death
provided:
1. he is insured under this Policy on the date of death, and
2. We receive proof of death within two (2) years after the date of death.
We will determine the amount of insurance payable based upon the attached Application.
BENEFICIARY
Each Insured’s beneficiary designation must be made on a form which We provide or on a form accepted by Us. If
two or more beneficiaries are named, payment of proceeds will be apportioned equally unless the Insured had
specified otherwise. The Policyholder may not be named as beneficiary.
Unless otherwise provided by an Insured, if a beneficiary dies before the Insured, We will divide that beneficiary’s
share equally between any remaining named beneficiaries.
If no named beneficiary survives the Insured or if no beneficiary is designated by the Insured, We will pay the
amount of insurance:
1. to the Insured’s spouse, if living; if not,
2. in equal shares to the then living natural or adopted children of the Insured, if any; if none,
3. in equal shares to the father and mother of the Insured, if living; if not,
4. to the estate of the Insured.
If a beneficiary is a minor, or is not able to give a valid release for any payment of benefits made, We will not make
payment until a claim is made by the person or entity which, by court order, has been granted control of the estate of
such beneficiary. This provision does not prevent Us from making payment to or for the benefit of a minor
beneficiary in accordance with the applicable state law.
If any benefits under this provision are to be paid to the estate of an Insured, We may pay an amount not greater than
$5,000 to any person We consider to be equitably entitled by reason of having incurred funeral or other expenses
incident to the Insured’s death. Any and all payments made by Us shall fully discharge Us in the amount of such
payment.
CHANGE OF BENEFICIARY
An Insured may change his beneficiary at any time by completing a change request form, or a form accepted by Us,
and sending it to the Policyholder. The Insured’s written request for change of beneficiary will not be effective until
it is recorded by the Policyholder. After it has been so recorded, it will take effect on the later of the date the
Insured signed the change request form or the date he specifically requested. If the Insured dies before the change
has been recorded, We will not alter any payment that We have already made. Any prior payment shall fully
discharge Us from further liability in that amount.
CONVERSION OF LIFE INSURANCE
Conversion if Eligibility Terminates:
An Insured may convert to an individual policy of life insurance if his life insurance, or a portion of it, ceases
because:
FDL1-504-999 8
1. he is no longer employed by the Policyholder; or
2. he is no longer in a class which is eligible for life insurance.
In either of these situations, he may convert all or any portion of his life insurance which was in force at the date of
termination.
Conversion if Policy is Terminated or Amended:
An Insured may also convert to an individual policy of life insurance if his life insurance ceases because:
1. life insurance benefits under the Policy cease; or
2. the Policy is amended making him ineligible for life insurance; however, in either of these situations,
he must have been insured under the Policy for at least five (5) years. The amount of insurance converted in either
of these situations will be the lesser of:
1. the amount of life insurance in force, less any amount for which the Insured becomes eligible under this or any
other group policy within 31days after the date his life insurance ceased; or
2. $10,000.
Conditions for Conversion:
We must receive written application and the first premium for the individual life insurance policy within 31 days
after insurance under the Policy ceases. No evidence of insurability will be required.
The individual policy will be a policy of whole life insurance. It will not contain disability benefits, accidental death
and dismemberment benefits or any other supplemental benefits.
The premium for the individual policy will be based on:
1. Our current rates based upon the applicant’s attained age on his nearest birthday; and
2. on the amount of the individual policy.
If application is made for an individual policy, the coverage under the individual policy will be effective on the day
following the 31-day period during which the applicant could apply for conversion.
If the Insured dies during a period when he would have been entitled to have an individual policy issued to him and
if he dies before such an individual policy became effective, We will pay the beneficiary the greatest amount of
group term life insurance for which an individual policy could have been issued, provided:
1. the death occurred during the 31-day period within which he could have made application; and
2. We receive proof of death within two (2) years of the date of death.
If life insurance benefits are paid under this Policy, payment will not be made under the converted policy, and
premiums paid for the converted policy will be refunded.
Notice. If the Policyholder fails to notify an Insured at least 15 days prior to the date insurance under the Policy
would cease, the Insured shall have an additional period within which to elect conversion coverage; but nothing
herein shall be construed to continue any insurance beyond the period provided for in the Policy. The additional
election period shall expire 15 days immediately after the Policyholder gives the Insured notice, but in no event shall
it extend beyond 60 days immediately after the expiration of the 31-day period explained above.
WAIVER OF PREMIUM
FDL1-504-999 9
We will continue an Insured’s life insurance benefit under this Policy without the further payment of life insurance
premium if he becomes Totally Disabled, provided:
1. he is insured under this Policy and is Actively at Work on or after the effective date of the Policy; and
2. he is under the age of 60; and
3. he provides Us with satisfactory written proof of Total Disability within 12 months after the date he became
Totally Disabled; and
4. his Total Disability has continued without interruption for at least 6 months; and
5. he is still Totally Disabled when he submits the proof of disability; and
6. all required premium has been paid.
The premium will be waived from the date We receive satisfactory written proof of Total Disability. Premium will
continue to be waived provided the Insured:
1. remains Totally Disabled; and
2. provides satisfactory written proof of continuing Total Disability upon request.
The Insured is responsible for obtaining initial and continuing proof of Total Disability.
The Insured will be covered for the amount of life insurance in force as of the date Total Disability commenced.
The amount of life insurance continued in force will be subject to any reduction in benefits as a result of age or
amendment to the Policy. This life insurance coverage will continue without the payment of premium until the
Insured is no longer Totally Disabled or reaches age 65, whichever occurs first.
We may have the Insured examined at reasonable intervals during the period of claimed Total Disability.
Continuation of life insurance under the Waiver of Premium provision shall end immediately and without notice if
the Insured refuses to be examined as and when required.
We will pay the amount of life insurance in force to the beneficiary if an Insured dies before furnishing satisfactory
proof of his Total Disability, provided:
1. the Insured dies within one year from the date he became Totally Disabled; and
2. We receive proof that the Insured was continuously Totally Disabled until the date of death; and
3. We receive proof of death not more than two (2) years after the death of the Insured.
If continuation of life insurance under the Waiver of Premium provision ceases, and the Insured is employed by the
Policyholder, his life insurance will continue provided premium payments begin on the next premium due date.
If continuation of life insurance under the Waiver of Premium provision ceases, and the Insured is no longer
employed by the Policyholder, he may apply for an individual life insurance policy in accordance with the
Conversion of Life Insurance provision of this Policy.
FDL1-504-999 10
ACCELERATED DEATH - TERMINAL ILLNESS BENEFIT
The benefit paid under this provision may be taxable. If so, an Insured or his beneficiary may incur a tax
obligation. As with all tax matters, the Insured or his beneficiary should consult a personal tax advisor to
assess the impact of the benefit. Receipt of this benefit may adversely affect the Insured’s eligibility for
Medicaid or other governmental benefits or entitlements.
ELIGIBILITY
This benefit only applies to Insureds with life insurance benefit amounts of $15,000 or more.
Coverage under the Accelerated Death - Terminal Illness Benefit is subject to the Deferred Effective Date provision.
An Insured must be Actively at Work on the date his coverage under this benefit becomes effective. If he is not
Actively at Work, the effective date of this coverage will be deferred until the first day he returns to Active Work.
BENEFIT
The benefit is 50% of the Insured’s group term life insurance amount in force on the date that We receive Proof that
he is Terminally Ill. This sum is limited to a maximum of $150,000 and a minimum of $7,500 and is payable only
once to any one Insured.
If the Insured’s group term life insurance will reduce, due to age, within 12 months after the date We receive Proof,
the benefit will be 50% of the reduced group term life insurance benefit.
This benefit does not apply to Accidental Death and Dismemberment benefits.
BENEFIT PAYMENT
We will pay the benefit during the lifetime of an Insured who is Terminally Ill if he or his legal representative elects
the Benefit and provides satisfactory Proof. The benefit will be paid in one sum to the Insured.
FDL1-504-999 11
EXCEPTIONS
The benefit will not be payable:
1. for any amount of group term life insurance which is less than $15,000; or
2. if the Insured becomes Terminally Ill as a result of:
a. attempted suicide, while sane or insane; or
b. self-inflicted injury; or
3. if the Insured’s group term life insurance benefit has been assigned; or
4. if the Insured’s group term life insurance benefit is payable to an irrevocable beneficiary, including notification
to Us that such benefit or a portion of such benefit is to be paid to a former spouse as part of a divorce or
separation agreement.
NOTICE AND PROOF OF CLAIM
The Insured must elect the benefit in writing on a form that is acceptable to Us. The Insured must furnish Proof that
he is Terminally Ill, including certification by a Medical Provider.
EFFECT ON INSURANCE
The benefit is in lieu of the group term life insurance benefit that would have been paid upon the Insured’s death.
When the benefit is paid:
1. the amount of group term life insurance otherwise payable upon the Insured’s death will be reduced by the
benefit;
2. the amount of group term life insurance which could otherwise have been converted to an individual contract
will be reduced by the benefit; and
3. the premium due for group term life insurance will be calculated on the amount of such insurance remaining in
force after deducting the benefit.
FDL1-504-999 12
ACCIDENTAL DEATH, DISMEMBERMENT, AND LOSS OF SIGHT
BENEFIT
BENEFIT
We will pay up to the Principal Sum set forth in the Application if an Insured loses his life or a member of his body
as a result of an Accident, while insured under this Policy. The amount payable is shown in the table below. The
loss must occur within 365 days of the Accident; and the loss must be the direct and sole result of the Accident and
independent of all other causes.
Table of Losses:
One-half of the Principal Sum
Principal Sum for Loss of: for Loss of:
Life Sight of One Eye
Both Hands One Hand
Both Feet One Foot
One Hand and One Foot
Sight of Both Eyes
One Hand and the Sight of One Eye
One Foot and the Sight of One Eye
With respect to hand or foot, Loss means actual and permanent severance from the body at or above the wrist or
ankle joint, as applicable. With respect to sight, Loss means entire and irrecoverable loss of sight.
The total amount of benefits payable for all losses to any one person resulting from any one Accident will not be
greater than the Principal Sum set forth in the Application.
We will pay benefits for loss of life to the same beneficiary(ies) named to receive life insurance benefits. Benefits
for all other losses will be paid to the Insured.
SEAT BELT BENEFIT
We will pay an additional benefit of the lesser of the Insured’s Principal Sum or $25,000. We will pay this benefit if
the Insured suffers loss of life as the result of a covered accident which occurs while he is driving or riding in an
Automobile, if:
1. the Automobile is equipped with Seat Belts;
2. the Seat Belt was in actual use and properly fastened at the time of the Accident; and
3. the position of the Seat Belt is certified in the official report of the accident or by the investigating officer. A
copy of the police accident report must be submitted with the claim.
If such certification is not available, and it is unclear whether the Insured was properly wearing Seat Belt(s), then
We will pay a fixed benefit of $1,000.
Automobile means a validly registered four-wheel passenger car (including Policyholder-owned cars), station
wagons, jeeps, pick-up trucks, and van-type vehicles.
Seat Belt means those belts that form an occupant restraint system.
FDL1-504-999 13
LIMITATIONS
We will not pay any benefits for a loss caused by or connected with:
1. suicide or attempted suicide;
2. intentionally self-inflicted injury, including but not limited to Russian roulette;
3. bodily or mental disease or treatment of these;
4. the Insured’s participation in, or as a result of his having participated in the commission of an assault or felony;
5. bacterial infection except pyogenic infection which occurs through or with an Accidental cut or wound;
6. war or any act of war, whether declared or undeclared;
7. travel or flight in an aircraft while a member of the crew, or while engaged in the operation of the aircraft, or
giving or receiving training or instruction in such aircraft;
8. the Insured’s being under the influence of any drug, (except those prescribed by a physician and used in the
manner prescribed), including narcotics, hallucinogens and gas or fumes, which are taken or inhaled
voluntarily;
9. voluntary poisoning; or
10. the Insured’s being Intoxicated. A concentration of 0.10% or more by weight of alcohol in the blood is
conclusive proof that the Insured is Intoxicated.
NOTICE OF CLAIM
If an Insured incurs a loss that may result in a claim for benefits under this Policy, written notice must be given to
Us at Our administrative office. This must be done within 20 days after the covered loss occurs. If notice cannot be
given within that time, it must be given as soon as reasonably possible. This notice must contain enough
information to identify the claimant.
CLAIM FORMS
When We receive written notice of a claim, We will send the claimant forms with which to file proof of loss. If
these forms are not given to the claimant within 15 days, he will be excused from filing the forms provided he sends
Us written proof of loss detailing the occurrence, the character and extent of the loss for which claim is made.
FDL1-504-999 14
PROOF OF LOSS
We must receive written proof of loss within 90 days after the date of the loss for which claim was made. If it can
be shown that it was not reasonably possible to furnish such proof and that such proof was furnished as soon as
reasonably possible, failure to furnish proof of loss within 90 days will not invalidate or reduce any claim.
However, except in the absence of legal capacity, proof of loss must be furnished no later than one (1) year from the
date such proof is required.
PHYSICAL EXAMINATION/AUTOPSY
Upon receipt of a claim, We may examine an Insured, at Our expense, at any reasonable time. We reserve the right
to perform an autopsy, at Our expense, if it is not prohibited by any applicable local law(s).
LEGAL ACTION
No action at law or in equity may begin prior to 60 days after We receive valid written proof of loss. No such action
may begin after 3 years from the day written proof of loss was required.
FDL1-504-999 15
PREMIUM PROVISIONS
We will charge the rates set forth on the face page of this Policy until the first anniversary of this Policy. However,
these rates may be changed on any premium due date if Policy provisions or benefits are changed.
Following the first Policy Anniversary, We may change the rates on any premium due date, but not more than once
in any 12-month period. We will notify the Policyholder in writing at least 31 days prior to a change in rates.
If the Policyholder is an association, the term Policy under this provision shall mean coverage provided to a
Participating Employer under the terms of this Policy.
PAYMENT OF PREMIUMS
The first premium is due on the Policy effective date. Subsequent premiums are due on the premium due dates set
forth in the Application.
Premium charges for new Insureds, for increases in insurance amounts, or for the addition of Dependent or any
Supplemental coverage will begin on the premium due date which coincides with or next follows the date of the add
or the change. Premium charges for terminated Employees, decreases in insurance amounts, or termination of
Dependent or Supplemental coverage will end on the premium due date which coincides with or next follows the
termination or the change in amount.
This method of charging premium will neither commence any insurance after the date it would otherwise begin nor
extend any insurance coverage beyond the date it would otherwise terminate pursuant to the applicable eligibility or
termination provisions of this Policy.
GRACE PERIOD
We will allow a grace period of 31 days for the payment of any premiums due except the first. Insurance coverage
shall continue in force during the grace period unless the Policyholder has given Us advance written notice of
cancellation in accordance with the terms of this Policy. If premium is not received by the end of the grace period,
this Policy will terminate as of the last date for which premium was paid.
The Policyholder is liable for premium due on coverage provided during the grace period.
If We receive written notice during the grace period that the Policy is to be canceled, We will cancel it as of the later
of:
1. the date requested in the cancellation notice; or
2. the date We receive such notice. The Policyholder must pay a pro rata premium for any coverage provided
during the grace period.
NONPARTICIPATING
This Policy does not share in the earnings of the company.
FDL1-504-999 16
TERMINATION PROVISIONS
TERMINATION OF EMPLOYEE COVERAGE
Insurance coverage will end for an Insured on the earliest of:
1. the date the Insured is no longer a member of a covered class; or
2. the date the Policy is canceled; or
3. the effective date of an amendment to this Policy which terminates insurance for the class to which the Insured
belongs; or
4. the date the Insured stops making any required contribution toward payment of premiums; or
5. the date the Insured is no longer Actively at Work; however,
if the Insured is no longer Actively at Work as a result of a disability, layoff, or leave of absence he may continue to
be eligible for group insurance coverage, except short term disability coverage, as follows:
Disability Until the end of the twelfth month following the month in which the disability began, provided all
premiums are paid when due.
Layoff Until the end of the month following the month during which the layoff began, provided all
premiums are paid when due.
Leave of Until the end of the month following the month in which the leave of absence began, provided all
Absence premiums are paid when due; or governed by the Employer’s Human Resource policy on family
and medical leaves of absence, for up to 12 weeks during a leave of absence elected under the
federal Family and Medical Leave Act of 1993, provided the leave of absence was approved in
advance and in writing by the Employer and all premiums are paid when due.
FDL1-504-999 17
TERMINATION OF POLICY
Termination of this Policy under any conditions will not prejudice any claim which is incurred while this Policy is in
force.
If the Policyholder fails to pay any premium within the grace period, this Policy will terminate as of the last date for
which premium was paid. Either We or the Policyholder may terminate this Policy by advance written notice
delivered at least 31 days prior to the termination date; but this Policy will not terminate during any period for which
premium has been paid. The Policyholder will be liable to Us for all premiums due and unpaid for the full period
for which this Policy is in force.
We may not renew coverage if:
1. the number of Employees insured is less than ten (10); or
2. less than 100% of the Employees eligible for any noncontributory insurance are insured for it; or
3. less than 75% of the Employees eligible for any contributory insurance are insured for it; or
4. the Policyholder fails:
a. to furnish promptly any information which We may reasonably require; or
b. to perform any other obligations pertaining to this Policy.
Termination may take effect on an earlier date when both the Policyholder and We agree.
If the Policyholder is an association, the term Policy under this provision shall mean coverage provided to a
Participating Employer under the terms of this Policy.
FDL1-504-999 18
GENERAL PROVISIONS
ENTIRE CONTRACT
This Policy, the attached Application, and the enrollment forms of the Insureds are considered to be the entire
contract.
STATEMENTS
We consider any statements made by the Policyholder or any Insured, in the absence of fraud, to be representations
and not warranties. No such statement shall be used in defense to a claim under the Policy unless it is contained in a
written application.
POLICY AMENDMENTS
This Policy may be changed at any time by a written agreement between the Policyholder and Us. Any Policy
amendment is subject to the law of the state in which it is delivered. Only Our executive officers are authorized to
amend this Policy. We are not bound by any agreement or promise made by someone other than Our executive
officers.
INDIVIDUAL CERTIFCATES
We will give the Policyholder a certificate to deliver to each Insured. It explains the insurance coverage provided
under the Policy, to whom benefits are payable, and the rights and conditions set forth in the conversion provision.
The Policyholder shall give a certificate to each Insured.
A certificate amendment will be sent to the Policyholder for delivery to each Insured if this Policy is amended.
INCONTESTABILITY
We will not contest the validity of the Policy, except for nonpayment of premium, after it has been in force for two
(2) years from its effective date. We will not contest the validity of an Insured’s insurance after his insurance has
been in force for two (2) years during his lifetime.
MISSTATEMENT OF AGE
If an Insured has misstated his age or the age of a Dependent, the true age will be used to determine:
1. the effective date or termination date of insurance; and
2. the amount of insurance; and
3. any other rights or benefits.
Premiums will be adjusted to reflect the premiums that would have been paid if the true age had been known.
FDL1-504-999 19
POLICYHOLDER RECORDS
The Policyholder must keep records which detail each Employee’s eligibility for benefits under this Policy. We may
examine this information at any time.
If an eligible Employee has informed the Policyholder of his intention to enroll for group insurance and has paid any
premiums, his insurance will not be made invalid solely due to a clerical error made by the Policyholder. However,
if We are not notified about the termination of any Employee, We will not be required to continue insurance beyond
the termination date set forth in the Policy.
TRUSTEE POLICYHOLDER
If the Trustee(s) of a trust fund or an association is (are) the Policyholder, We will rely on the signature of the
Trustee(s) or representatives named to act on behalf of the trust or association. The trust agreement shall not operate
to waive or alter this Policy.
CONFORMITY WITH STATE LAW
If any part of this Policy does not conform to a state statute in the state in which it is issued or delivered, it is
amended to conform with the minimum requirements of the statutes of that state.
ASSIGNMENT
The life insurance benefits provided under this Policy are assignable by an Insured. In addition, the Insured may
assign to anyone other than the Policyholder any incident of ownership he may possess. We are not responsible for
the validity or legal effect of any assignment. Collateral assignments, by whatever name called, are not permitted.
RETENTION OF DISCRETION
Fort Dearborn Life Insurance Company shall have the exclusive right to interpret the terms of the Certificate,
Schedule of Benefits, Riders and Endorsements. The decision about whether to pay any claim, in whole or in part,
is within the sole discretion of Fort Dearborn Life and such decisions shall be final and conclusive.
FDL1-504AD-1002
FORT DEARBORN LIFE INSURANCE COMPANY
(herein called We, Us, Our)
AMENDATORY RIDER
This Rider is made part of the Policy or Certificate to which it is attached. This Rider amends the Section entitled
"Accidental Death, Dismemberment and Loss of Sight Benefit" and is subject to all the provisions of the Policy not
in conflict with the provisions of this Rider.
The “Accidental Death, Dismemberment and Loss of Sight Benefit" Section of the Policy and Certificate is deleted
in its entirety and replaced with the following:
ACCIDENTAL DEATH & DISMEMBERMENT BENEFIT (AD&D)
If, while insured under this Policy, an Insured suffers an Injury in an Accident, We will pay for those Losses set
forth in the subsection entitled "Table of Losses" below. The amount paid will be as stated in the Table of Losses
but not more than the Principal Sum set forth in the Application. The Loss must:
1. occur within 365 days of the Accident; and
2. be the direct and sole result of the Accident; and
3. be independent of all other causes.
TABLE OF LOSSES
Principal Sum for Loss of:
One-half of the Principal Sum
for Loss of:
One-Quarter the Principal Sum for
Loss of:
Life Sight of One Eye Thumb and Index Finger of Same Hand
Both Hands One Hand
Both Feet One Foot
One Hand and One Foot Speech or Hearing
Speech and Hearing
Sight of Both Eyes
One Hand and the Sight of One Eye
One Foot and the Sight of One Eye
With respect to hand or foot, loss means actual and permanent severance from the body at or above the wrist or
ankle joint, as applicable. With respect to eyes, speech and hearing, loss means entire and irrecoverable loss of sight,
speech or hearing. With respect to thumb and index finger, loss means complete severance of entire digit at or above
joints.
The total amount of AD&D benefits payable for all Losses for any Insured resulting from any one Accident will not
be greater than the Principal Sum set forth in the Application.
Except as provided in a particular benefit, We will pay benefits for Loss of life to the same beneficiary(ies) named to
receive life insurance benefits. Benefits for all other Losses will be paid to the Insured.
FDL1-504AD-1002
SEAT BELT BENEFIT
We will pay an additional benefit, the Seat Belt Benefit, of the lesser of the Insured’s Principal Sum or $25,000 if the
Principal Sum under the AD&D Benefit is payable for Loss of the Insured’s life as the result of an Accident which
occurs while the Insured is driving or riding in an automobile, if:
1. the automobile is equipped with Seat Belts;
2. the Seat Belt was in actual use and properly fastened at the time of the Accident;
3. the position of the Seat Belt is certified in the official report of the Accident or by the investigating officer. A
copy of the police Accident report must be submitted with the claim; and
4. the Insured was driving or riding in an automobile driven by a licensed driver who was neither:
a. intoxicated or driving while impaired. Intoxication and impairment shall be determined by the law of the
jurisdiction in which the Accident occurs, with or without conviction; nor
b. under the influence of any narcotic, hallucinogen, barbiturate, amphetamine, gas or fumes, poison or any
other controlled substance as defined in Title II of the comprehensive Drug Abuse Prevention and Control
Act of 1970, as now or hereafter amended, unless as prescribed by a licensed physician and used in the
manner prescribed. Conviction is not necessary for a determination of being under the influence.
If such certification is not available and if it is unclear whether the Insured was properly wearing a Seat Belt, then
We will pay an additional benefit of $1,000.
Seat Belt means those belts that form an occupant restraint system.
AIR BAG BENEFIT
We will pay an additional benefit, the Air Bag Benefit, equal to 5% of the Principal Sum of the AD&D Benefit if the
Principal Sum under the AD&D Benefit is payable for Loss of the Insured’s life as the result of an Accident which
occurs while the Insured is driving or riding in an automobile provided that:
1. the Insured was positioned in a seat that was equipped with a factory-installed Air Bag;
2. the Insured was properly strapped in the Seat Belt when the Air Bag inflated; and
3. the police report establishes that the Air Bag inflated properly upon impact.
The maximum Air Bag Benefit payable is $5,000.00. If it is unclear whether the Insured was properly wearing Seat
Belt(s) or if it is unclear whether the Air Bag inflated properly, then the Air Bag Benefit will be $1,000.
Air Bag means an inflatable supplemental passive restraint system installed by the manufacturer of the Automobile,
or proper replacement parts as required by the Automobile manufacturer’s specifications, that inflates upon collision
to protect an individual from Injury and death. An Air Bag is not considered a Seat Belt.
REPATRIATION BENEFIT
We will pay an additional benefit, the Repatriation Benefit, of up to $5,000 of the Principal Sum of the AD&D
Benefit for the preparation and transportation of an Insured’s body to a mortuary if:
1. the Principal Sum under the AD&D Benefit is payable for Loss of the Insured's life; and
2. the Insured’s death occurs at least 75 miles away from the Insured’s principal residence.
FDL1-504AD-1002
EDUCATION BENEFIT
We will pay an additional benefit, the Education Benefit, to the Insured Employee’s Dependent Student if the
Principal Sum under the AD&D Benefit is payable for Loss of the Insured Employee's life.
Definitions which apply to the Education Benefit:
Student means a Dependent Child who, on the date of the Insured Employee’s death, is:
1. A full-time post-high school student in a school of higher education; or
2. A student in the 12th grade but who becomes a full-time post-high school student in a school of higher education
within 365 days after the Insured Employee’s death.
School of higher education means an institution which:
1. is legally authorized by the State in which it is located; and
2. provides either a program for:
a. Bachelor’s degrees or not less than a two year program with full credit towards a Bachelor’s degree; or
b. Gainful employment as long as such program is at least one year of training; and
3. is accredited by an Agency or association recognized by the U.S. Department of Education under the Higher
Education Assistance Act as may be amended from time to time.
Eligible Dependent Child means any unmarried child of the Insured (whether natural, step, foster or adopted) who
is:
1. at least 15 days but less than 18 years of age and dependent on the Insured for support and maintenance; and
2. not in active military service.
Eligibility will continue to age 23 for Dependent Children who are not employed full-time and are enrolled as a full-
time student in a recognized school and dependent on the Insured Employee for support and maintenance.
Eligibility will continue past the age limit for Dependent Children who are primarily dependent upon the Insured for
support and who cannot work to support themselves due to a physical or mental incapacity which began before the
age limit was reached. Proof of such incapacity must be provided to Us upon request. Note: No eligible person
may be covered more than once under this Policy. If a person is covered as an Employee, he cannot be covered as a
Spouse or Dependent Child of another Employee.
Amount of Benefit: The maximum Dependent Education Benefit for each dependent Student shall equal the lesser
of the Insured Employee’s Principal Sum or $12,000.
Payment of Benefit: We will pay the Dependent Education Benefit in four equal annual installments. We will only
pay one Dependent Education Benefit to any one dependent Student during any one school year. If the dependent
Student is a minor, We will pay the benefit to the legal representative of the minor.
When Benefit Ends: A dependent Student will no longer be eligible to receive the Dependent Education Benefit
upon the earlier of the following:
1. Our payment of the fourth installment of the Dependent Education Benefit on behalf of or to the dependent
Student; or
2. At the end of the period during which Due Proof must be submitted if no Due Proof is submitted.
Special Child Education Benefit: If the Insured Employee’s Eligible Dependent Child does not qualify as a
Student, but is enrolled in an elementary or high school, We will pay a Child Education Benefit in the amount of
$1,000. This benefit is payable once upon proof that the Insured Employee has died as a result of an accident for
which the Accidental Death & Dismemberment benefit is payable and that, within 12 months after the Insured
Employee’s death, the Insured Employee’s Eligible Dependent Child is a full-time student in an elementary or high
school.
FDL1-504AD-1002
LIMITATIONS
We will not pay any benefit for any Loss that, directly or indirectly, results in any way from or is contributed to by:
1. any disease or infirmity of mind or body, and any medical or surgical treatment thereof; or
2. any infection, except a pus-forming infection of an accidental cut or wound; or
3. suicide or attempted suicide, while sane or insane; or
4. any intentionally self-inflicted Accident; or
5. war, declared or undeclared, whether or not the Insured is a member of any armed forces; or
6. travel or flight in an aircraft while a member of the crew, or while engaged in the operation of the aircraft, or
giving or receiving training or instruction in such aircraft; or
7. commission of, participation in, or an attempt to commit an assault or felony; or
8. being under the influence of any narcotic, hallucinogen, barbiturate, amphetamine, gas or fumes, poison or any
other controlled substance as defined in Title II of the comprehensive Drug Abuse Prevention and Control Act
of 1970, as now or hereafter amended, unless as prescribed by the Insured’s licensed physician and used in the
manner prescribed. Conviction is not necessary for a determination of being under the influence; or
9. intoxication as defined by the laws of the jurisdiction in which the accident occurred. Conviction is not
necessary for a determination of being intoxicated; or
10. active participation in a riot. “Riot” means all forms of public violence, disorder, or disturbance of the public
peace, by three or more persons assembled together, whether with or without a common intent and whether or
not damage to person or property or unlawful act is the intent or the consequence of such disorder.
FDL1-504AD-1002
NOTICE OF CLAIM
If an Insured incurs a loss that may result in a claim for benefits under this Policy, written notice must be given to
Us at Our administrative office. This must be done within 20 days after the covered loss occurs. If notice cannot be
given within that time, it must be given as soon as reasonably possible. This notice must contain enough
information to identify the claimant.
CLAIM FORMS
When We receive written notice of a claim, We will send the claimant forms with which to file proof of loss. If
these forms are not given to the claimant within 15 days, he will be excused from filing the forms provided he sends
Us written proof of loss detailing the occurrence, the character and extent of the loss for which claim is made.
PROOF OF LOSS
We must receive written proof of loss within 90 days after the date of the loss for which claim was made. If it can
be shown that it was not reasonably possible to furnish such proof and that such proof was furnished as soon as
reasonably possible, failure to furnish proof of loss within 90 days will not invalidate or reduce any claim.
However, except in the absence of legal capacity, proof of loss must be furnished no later than one (1) year from the
date such proof is required.
For the Education Benefit, Proof of Loss must:
1. Include proof of dependent Student status; and
2. Be submitted no later than
a. Two months after completion of course work for that particular school year if the dependent Student is
enrolled in a school of higher learning at the time of the Insured’s death. School year shall be deemed to
begin on September 1st and end on August 31st; or
b. Within six (6) months after enrollment in a school of higher learning if the dependent Student is in the 12th
grade at the time of the Insured’s death. After the first year in a school of higher learning, due proof must
be submitted in accordance with paragraph (1) in this Notice of Claim Section.
PHYSICAL EXAMINATION/AUTOPSY
Upon receipt of a claim, We may examine an Insured, at Our expense, at any reasonable time. We reserve the right
to perform an autopsy, at Our expense, if it is not prohibited by any applicable local law(s).
LEGAL ACTION
No action at law or in equity may begin prior to 60 days after We receive valid written proof of loss. No such action
may begin after 3 years from the day written proof of loss was required.
President
RATE ADDENDUM
Coverage Initial Monthly Rate
Employee Life (per $1,000) $.xx
Accidental Death & Dismemberment (per ($1,000) $.xx
*This ERISA addendum only applies if the Policy is part of or is an ERISA Plan.
11/1/03
*ERISA
To the extent these provisions conflict with any provision of the Policy, these provisions take precedence over the
Policy. The Employer has established this Benefit Plan (the "Plan") as an Employee welfare benefit plan subject to
the Employee Retirement Income Security Act of 1974, as amended, ("ERISA"). The Plan consists of an insurance
policy(ies), including the Master Application and any Amendments (collectively, the "Policy").
ALLOCATION OF AUTHORITY
Plan Administrator
The Employer shall be the Plan Administrator and Named Fiduciary of the Plan. As such, the Employer has full
discretionary and final authority and control over the Plan. This authority includes all of the power and authority
contemplated by ERISA with respect to the Plan, including but not limited to the authority to:
1. Appoint or employ those parties necessary to administer the Plan;
2. Prescribe the rules and procedures under which the Plan shall operate;
3. Communicate with employees about their participation in the Plan;
4. Review and approve any financial or other reports prepared by any party appointed under paragraph (1);
5. Establish a funding policy consistent with the purposes of the Plan and ERISA; and
6. Amend, terminate or suspend the Plan in accordance with the procedure set forth herein.
The Plan Administrator appoints the Insurer to:
1. Resolve all matters when a review pursuant to the claims procedures has been requested;
2. Interpret, establish and enforce rules and procedures for the administration of the Policy and any
claim under it; and
3. Determine eligibility of Employees and Dependents for benefits and their entitlement to and the amount of
benefits under the Policy.
The Insurer shall not be a fiduciary for any other purpose. Nothing in the Plan shall affect the obligations of the
Insurer with respect to the Policy. If any uncertainty shall arise between the information in the certificate or the
Summary Plan Description ("SPD") and the Policy, or if any point is not covered in the certificate or SPD, the terms
of the Policy will govern in all cases. Benefits will be paid under this Plan only if the Plan Administrator, or the
Insurer if so delegated by the Plan Administrator, decides in its full discretion and final authority that the applicant is
entitled to them.
AMENDMENT & TERMINATION
Without consent of the participants and their beneficiaries, the Employer may amend or terminate, in whole or in
part, the Plan at any time. Any such amendment or termination shall be according to the Employer’s authorized
procedures. Any such authorization may be either specific to such Plan or persons authorized to act on behalf of the
Employer or may be general as to the duties of such person. Any amendment or termination shall be in writing and
attached to the Plan. Except for termination, any amendments affecting the Policy must also be approved in writing
by an officer of the Insurer and shall be effective as of the date agreed to, in writing, by the Employer and the
Insurer. Notwithstanding anything to the contrary in this document, the Policy shall terminate according to the
provisions in the Policy.
11/1/03
FUNDING
The Policy is a guaranteed benefit policy as defined in Sec.401(b)(2) of ERISA. The Policy is an asset of the
Policyholder (or Employer Member). No assets of the Insurer are assets of or under the Plan. The Plan may be
contributory or non-contributory as stated in the Policy.
CLAIMS REVIEW PROCEDURES
*Disability Insurance Plans
*(Applies to the Waiver of Premium based on disability in Life Policies).
When the Insured or the Insured’s Beneficiary are eligible to receive benefits, the Insured or the Insured’s
Beneficiary or authorized representative (collectively, the "claimant") must notify the Plan Administrator by
submitting the proper form. This may be done by sending notice of the claim to the Plan Administrator who has
been appointed to assist the Insurer in the claims processing for this Plan or by contacting the Insurer directly at:
Claims Department
Fort Dearborn Life Insurance Company
2400 Lakeside Blvd.
Richardson, TX. 75082-7399
1-800-778-2281
The Insurer will give the claimant a written response to the claim, usually within 45 days. The time for decision
may be extended for two additional 30 day periods provided that, prior to any extension period, the Insurer notifies
the claimant in writing that an extension is necessary due to matters beyond the control of the Plan, identifies those
matters and gives the date by which it expects to render its decision. If the claim is extended due to the claimant’s
failure to submit information necessary to decide the claim, the time for decision shall be tolled from the date on
which the notification of the extension is sent to the claimant until the date the Insurer receives the claimant’s
response to the request. This period will be no longer than 45 days after the Insurer has requested the information.
At that time the Insurer will decide the claimant’s claim based on the information the Insurer has at that time.
If the claim is denied, in whole or in part, the claimant will receive a written notice giving the following:
- the reason for the denial;
- the Policy provisions on which the denial is based;
- an explanation of what other information, if any, may be needed to process the claim and why it is needed;
- the steps that have to be followed to have the claim reviewed;
- a statement concerning the right to bring a civil action under section 502(a) of ERISA after the appeal is
filed and a written denial on appeal is given; and
- if an internal rule, guideline, protocol, or other similar criterion was relied upon in making the denial, either
(i) the specific rule, guideline, protocol or other similar criterion; or (ii) a statement that such a rule,
guideline, protocol or other similar criterion was relied upon in making the denial and that a copy will be
provided free of charge to the claimant upon request; and
- if denial is based on medical judgement, either (i) an explanation of the scientific or clinical judgement for
the determination, applying the terms of the Plan to the claimant’s medical circumstances, or (ii) a
statement that such explanation will be provided to the claimant free of charge upon request.
11/1/03
If the claim has been denied, in whole or in part, it may be appealed to the Insurer for a full and fair review. The
claimant has at least 180 days to appeal from the claim denial.
The claimant may:
a) request a review upon written application within 180 days of the claim denial;
b) request, free of charge, copies of all documents, records and other information relevant to the claim; and
c) submit written comments, documents, records and other information relating to the claim, without regard to
whether such information was submitted or considered in the initial benefit determination.
The Insurer will make a decision no more than 45 days after receiving the appeal. The time for decision may be
extended for one additional 45 day period provided that, prior to the extension, the Insurer notifies the claimant in
writing that an extension is necessary due to special circumstances, identifies those circumstances and gives the date
by which it expects to render its decision. If the claim is extended due to the claimant’s failure to submit information
necessary to decide the claim on appeal, the time for the Insurer’s decision shall be tolled from the date on which the
notification of the extension is sent to the claimant until the date the Insurer receives the claimant’s response to the
request. The written decision will include specific references to the Plan provisions on which the decision is based
and any other notice(s), statement(s) or information required by applicable law.
Life Insurance Plans
A decision will be made by the Insurer no more than 90 days after receipt of due proof of loss, except in special
circumstances (such as the need to obtain further information), but in no case more than 180 days after the due proof
of loss is received. The written decision will include specific reasons for the decision and specific references to the
Plan provisions on which the decision is based.
If the claim is denied, in whole or in part, the claimant will receive a written notice giving the following:
- the reason for the denial;
- the Policy provisions on which the denial is based;
- an explanation of what other information, if any, may be needed to process the claim and why it is needed;
- the steps that have to be followed to have the claim reviewed;
- a statement of your right to bring civil action on denial of your appeal.
Any denied claim may be appealed to the Insurer for a full and fair review. The claimant may:
a) request a review upon written application within 60 days of receipt of claim denial;
b) review pertinent documents; and
c) submit issues and comments in writing.
A decision will be made by the Insurer no more than 60 days after receipt of the request for review, except in special
circumstances (such as the need to obtain additional evidence), but in no case more than 120 days after the request
for review is received. The written decision will include specific reasons for the decision and specific references to
the Plan provisions on which the decision is based.
FORT DEARBORN LIFE
INSURANCE COMPANY
Administrative Office:
2400 Lakeside Blvd. • Richardson, Texas 75082-7399
Town of Fountain Hills
Town Council Agenda Action Form
Meeting Type: Regular Meeting Meeting Date: August 17, 2006
Submitting Department: Administration Contact Person: Ghetti
Consent: Regular: Requesting Action: Report Only:
Type of Document Needing Approval (Check all that apply):
Public Hearing Resolution Ordinance
Agreement Emergency Clause Special Event Permit
Special Consideration Intergovernmental Agreement Acceptance
Grant Submission Liquor/Bingo License Application Plat
Special Event Permit Special/Temp Use Permit
Other:
Council Priority (Check Appropriate Areas):
Education Public Fitness Library Services
Public Safety Community Activities Economic Development
Public Works Human Service Needs Parks & Recreation
Town Elections Community Development
Regular Agenda Wording: CONSIDERATION of approving a liquor license APPLICATION for
Ronald Schmitt (Bruno’s Sports Barr and Grille, LLC) located at 16737 E. Parkview Ave., Fountain
Hills, AZ. This request is for a series #6 license.
Staff Recommendation: Approve Fiscal Impact: No $
Purpose of Item and Background Information: The various departmental recommendations have been
provided for the council’s review. There were no issues that required a response from the Building Safety or
Public Works. Therefore, staff’s unanimous recommendation is for the Council to recommend approval of this
liquor license application.
List All Attachments as Follows: Application front page, staff departmental recommendations, memo from law
enforcement.
Type(s) of Presentation: None.
Signatures of Submitting Staff:
CONTRACT
BETWEEN
THE TOWN OF FOUNTAIN HILLS
AND
CONCAST CORPORATION
FOR THE
DESERT VISTA SKATE PARK
PROJECT NO. PR 2006-02
THIS CONTRACT (this “Contract”) is made as of August 18, 2006, between the TOWN
OF FOUNTAIN HILLS, an Arizona municipal corporation (the “Town”) and CONCAST
CORPORATION, an Arizona corporation (the “Contractor”).
RECITALS
A. The Town issued an Invitation for Bid, No. #PR 2006-02 on August 7, 2006 (the
“IFB”), in connection with its Desert Vista Skate Park (the “Project”) for all labor, materials and
equipment necessary to accomplish the construction required under this Contract (the “Work”).
B. Contractor responded to the IFB and submitted a bid for the Work. Contractor’s
bid was the lowest, qualified bid received by the Town.
C. The Town desires to enter into this Contract with the Contractor for the Work.
D. The Town’s Contract Administrator for this Contract shall be the Town’s Parks
and Recreation Director or authorized designee.
AGREEMENT
NOW, THEREFORE, in consideration of the foregoing recitals, which are incorporated
herein by reference, and the following mutual covenants and conditions, the Town and the
Contractor hereby agree as follows:
1. GENERAL.
1.1 Term of Contract. The term of this Contract shall be from August 18,
2006, through December 31, 2006. Work shall not commence until the Notice to Proceed,
attached hereto as Exhibit A and incorporated herein by this reference, is executed by the Town.
Work shall be deemed complete upon the Town’s execution of the Contractor’s Notice of Final
Acceptance, attached hereto as Exhibit B and incorporated herein by this reference.
1.2 Scope of Work. Contractor shall perform the Work as set forth in
accordance with the (i) terms and conditions set forth in this Contract, (ii) Bidder’s Submission
comprising the Bid Form, Price Sheet and List of Subcontractors, Equipment and Special Worker
Qualifications attached hereto as Exhibit C and incorporated herein by this reference, (iii) Special
Terms and Conditions, attached hereto as Exhibit D and incorporated herein by this reference,
(iv) Technical Specifications prepared by Site Design Group, Inc. and dated May 3, 2006
669417.1
attached hereto as Exhibit E and incorporated herein by this reference, (v) Construction
Drawings prepared by Site Design Group, Inc. and dated May 3, 2006, a list of which is attached
hereto as Exhibit F and incorporated herein by this reference, (vi) applicable sections of the
Maricopa Association of Governments (“MAG”) Uniform Standard Specifications for Public
Works Construction (the “MAG Specifications”), which are hereby incorporated herein by this
reference and (vi) Work Schedule, attached hereto as Exhibit G and incorporated herein by this
reference.
1.3 Contract Price. The Town shall pay Contractor a price not to exceed
$326,702.00 (the “Contract Price”) for the Work, as set forth in the Price Sheet attached hereto as
part of Exhibit C.
1.4 Laws And Regulations. The Contractor shall keep fully informed of all
rules, regulations, ordinances, statutes or laws affecting the Work herein specified, including the
following: (i) existing and future Town and County ordinances and regulations, (ii) state and
federal laws and (iii) Occupational Safety and Health Administration (“OSHA”) standards.
1.5 Rights of Way. The Town will provide rights-of-way or easements for all
Work specified under this Contract, and the Contractor shall not enter or occupy with men, tools,
equipment or materials any private ground outside the property of the Town without the written
consent of the owner thereof. The Contractor, at his own expense, is responsible for the
acquisition of any additional easements or rights-of-way.
1.6 Inspection, Safety and Compliance. Contractor has inspected the jobsite
and has thoroughly reviewed the Contract including, without limitation, the Technical
Specifications and Construction Drawings attached as Exhibit E and Exhibit F, respectively, as
the same may be revised by the Town, and is not relying on any opinions or representations of
the Town. Contractor agrees to perform and complete such Work in strict accordance with the
Contract and under the general direction of the Town. Contractor agrees that any exclusions of
any Work must be approved in writing by the Town prior to acceptance of this Contract or same
shall not be excluded hereunder. Contractor is responsible for all safety precautions and
programs and shall provide all protection and necessary supervision to implement said
precautions and programs. Contractor shall take all reasonable precautions for the safety of and
provide reasonable protection to prevent damage, injury or loss to: (i) employees or others on the
Project, (ii) the Work and materials and (iii) other property at the Project or adjacent thereto.
Contractor shall designate a responsible person on the Project whose duty shall be prevention of
accidents. Contractor shall provide all competent supervision necessary to execute all Work and
any Work incidental thereto in a thorough, first-class, workmanlike manner. It is Contractor’s
responsibility that all of the Work and any work incidental thereto conforms to, and is performed
in accordance with, all applicable federal, state, county and Town laws, codes, ordinances,
regulations (including NPDES and air pollution) and orders of public authorities bearing on
performance of the Work.
1.7 Changes in the Work. The Town may, without invalidating this Contract,
order changes in the Work consisting of additions, deletions or other revisions to the Contract
and the Contract Price and the Contract Time shall be adjusted as provided below. The Contract
Price and/or the Contract Time may only be changed by the Town’s written directive or approval
669417.1
authorizing said change, and said changes shall be performed under the applicable conditions of
the Contract. The Contract Price shall be adjusted as a result of a change in the Work as follows:
a. Additions: When the Town increases the scope of the Work,
Contractor will perform the increased work pursuant to Contractor’s Unit Prices set forth on the
Price Sheet.
b. Deletions: When the Town decreases the Work resulting in a
decrease in Contractor’s quantity of the Work, the Town shall be allowed a decrease in the
Contract Price amounting to the quantity of the deleted Work multiplied by the Contractor’s Unit
Prices.
c. Estimating: Whenever the Town is considering a change to the
Work, Contractor shall promptly, and in any event within three business days, estimate the price
of the contemplated additional or deleted Work in good faith and as accurately as is then
feasible. The estimate shall show quantities of labor, material and equipment and shall be
pursuant to the rates set forth in the Contractor Bid.
1.8 Payment. Payment shall be conditioned upon Contractor’s compliance
with the payment terms and conditions set forth below, and payment shall be made within 30
days of Contractor’s full compliance with said terms and conditions. Contractor expressly
acknowledges and agrees that (i) the Contract Price is an estimated amount based upon a Town
engineer’s estimate of the quantities of the materials deemed necessary to perform the Work and
(ii) the amount of any payment to be made pursuant to this Contract shall be determined by the
field-measured quantities of materials actually installed by Contractor. Material or equipment
delivered to the Project by or on behalf of Contractor shall not constitute material or equipment
furnished in the performance of the Work until same has been incorporated into the
improvements constituting the Project. Payment shall not constitute acceptance by the Town or
evidence thereof of any Work performed.
a. Retention: Until the Work is complete and accepted by the
Town’s engineer and the Town Engineer has approved application for payment of retention, the
Town will pay 90% of the amount due Contractor on account of progress payments, with the
Town retaining 10% until the Project is complete (the “Retention”).
b. Progress Payments: Except as provided in subsection 1.8(d)
below, progress payments shall be made in monthly installments for work satisfactorily
completed and materials incorporated into the Project. On a monthly basis, Contractor shall
submit its itemized application for payment, supported by such data substantiating Contractor’s
right to payment as the Town Engineer may require or as required by this Contract. The Town
shall have the right to withhold payment to Contractor until Contractor furnishes satisfactory
evidence that all bills for labor, materials or other liabilities in connection with the requested
payment have been paid to date. The Town shall have the right to offset sums due Contractor
hereunder against any and all sums owed to the Town by Contractor or to protect against any
asserted claims until the claim has been adjusted by the Contractor to the Town’s satisfaction,
regardless of whether Contractor may have posted a payment or performance bond.
669417.1
c. Form of Payment: The Town may pay Contractor by check made
payable to Contractor or by joint check made payable to Contractor and any subcontractor,
lower-tier subcontractor or materialmen.
d. Bulk Material Orders: With the prior written approval of the
Town, Contractor may advance order the bulk delivery of work materials to be incorporated into
the Work over the course of this Contract, and upon delivery and receipt of supplier invoice
either directly to the Contractor, or to the vendor or by joint check to Contractor and vendor and
shall receive a full release for the amount paid from vendor and Contractor. Contractor agrees to
assume full responsibility for the safekeeping of all said materials and shall guarantee to the
Town that said materials shall remain safe from theft or damage from any and all causes (unless
caused by the sole negligence of the Town). Contractor shall immediately replace, repair or
restore said materials to their original condition so as to not cause any delay in the Work, and
Contractor shall indemnify and hold harmless the Town from and against any and all loss, cost,
liability or expense resulting from any loss or damage to any of the materials described herein
from any cause unless due to the Town’s sole negligence. Should the Town have reason to
believe Contractor is not properly safeguarding any of the said materials, the Town shall have the
right, but not the affirmative duty, to immediately take such steps as it deems necessary to do so,
including removing Contractor from the job, replacing any materials or expending any sums to
properly carry out Contractor’s responsibility hereunder, and any amounts so expended shall be
billed back to Contractor or deducted from any sums then or thereafter due to Contractor.
Contractor shall fully insure all materials stored on site as required by the Town, and if such
insurance is not obtained due to a lack of insurable interest, the Town shall have the right to
obtain such insurance and charge the amount thereof back to Contractor or deduct said amount
from any funds then or thereafter due to Contractor.
e. Final Progress Payment: Upon Contractor’s application for final
progress payment as provided below, the Town shall make payment in an amount determined by
field measuring the quantities of materials actually installed on the Project and computing the
payment amount pursuant to the Price Sheet attached hereto as part of Exhibit C. When
Contractor considers the Work complete, Contractor shall submit the Final Pay Estimate,
attached hereto as Exhibit H and incorporated herein by this reference, in conjunction with the
submission of Contractor’s final invoice. All quantities will be subject to verification by the
Town. Final payment constituting the unpaid balance of the Contract Price, excluding the
Retention, shall be due 30 days after the Town has accepted the Work.
f. Payment of Retention: Payment of the Retention shall be
conditioned upon the submittal to, and approval by, the Town of “AS-BUILT” drawings (if not
supplied by the Town Engineer), operating instructions and manuals, equipment warranties and
complete service and maintenance instructions for all equipment warranties and complete service
and maintenance instructions for all equipment furnished under this Contract. Payment of the
Retention shall not be due from the Town until the Town:
i. determines the Work acceptable under this Contract and the
Contract is fully performed;
ii. receives final approval of the Work by any other
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governmental agencies and political subdivisions having jurisdiction;
iii. receives Contractor’s affidavit that all payrolls, bills for
materials and equipment, and other indebtedness connected with the Work for
which the Town might in any way be responsible have been paid or otherwise
satisfied; and
iv. determines that Contractor has completed the correction or
repair of any discovered condition required by the Town to be corrected or
repaired.
1.9 Federal Funding. It is the responsibility of the Contractor to determine if
federal wage rates apply to the Work. It is also the responsibility of the Contractor to incorporate
any necessary amounts in the Bid to accommodate for required federal record keeping and
necessary pay structures. The Contractor should contact the Town regarding any applicable
Davis Bacon wage rates.
1.10 Traffic Regulations. All traffic affected by the Work under this Contract
shall be regulated in accordance with the City of Phoenix-Traffic Barricade Manual, revised July
1998 (the “Barricade Manual”) which is incorporated herein by reference; provided, however,
that this Contract shall govern in a conflict with the terms of the Barricade Manual. At the time
of the pre-construction conference, the Contractor shall designate an employee who is well
qualified and experienced in construction traffic control and safety to be responsible for
implementing, monitoring and altering traffic control measures, as necessary. At the same time
the Town will designate a representative who will be responsible to see that all traffic control and
any alterations are implemented and monitored to the extent that traffic is carried through the
Work area in an effective manner and that motorists, pedestrians, bicyclists and workers are
protected from hazard and accidents.
a. The following shall be considered major streets: All major
parkway, mile (section line), arterial and collector (mid-section line and quarter section line)
streets so classified by the Town.
b. All traffic control devices required for the Work under this
Contract shall be the responsibility of the Contractor. The Contractor shall place advance
warning signs (such as REDUCE SPEED, LOOSE GRAVEL, 25 MPH SPEED LIMIT and DO
NOT PASS) in accordance with the Barricade Manual.
c. The Contractor shall provide, erect and maintain all necessary
flashing arrow boards, barricades, suitable and sufficient warning lights, signals and signs and
shall take all necessary precautions for the protection of the Work and safety of the public. The
Contractor shall provide, erect and maintain acceptable and adequate detour signs at all closures
and along detour routes.
d. All barricades and obstructions shall be illuminated at night, and
all safety lights shall be kept burning from sunset until sunrise. All barricades and signs used by
the Contractor shall conform to the standard design generally accepted for such purposes and
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payment for all such services and materials shall be considered as included in the other pay items
of the Contract.
e. The Contractor shall ensure that all existing traffic signs are erect,
clean and in full view of the intended traffic at all times. Street name signs at major street
intersections shall be maintained erect at all times. If these signs should interfere with
construction, the Contractor shall notify the Town Engineer at least 48 hours in advance for
Town personnel to temporarily relocate said signs. The Town Engineer will direct the
Contractor as to the correct positions to re-set all traffic and street name signs to permanent
locations when notified by the Contractor that construction is complete.
f. When construction activities or traffic hazards at the construction
site require the use of flagmen, it shall be the Contractor’s responsibility to provide trained
flagmen to direct traffic safely.
g. Manual traffic control shall be in conformity with the Barricade
Manual, except that the designated liaison officer shall be contacted at the Fountain Hill's Police
Department.
h. When traffic hazards at construction sites warrant the use of
certified police personnel to direct traffic, arrangements must be made with the liaison officer at
the Fountain Hills Police Department.
i. The assembly and turnarounds of the Contractor’s equipment shall
be accomplished using adjacent local streets when possible.
j. Equipment used and/or directed by the Contractor shall travel with
traffic at all times. Supply trucks shall travel with traffic except when being spotted. Contractor
shall provide a flagman or off-duty, uniformed officer to assist with spotting.
k. During construction, it may be necessary to alter traffic control.
Any such alterations shall be in accordance with the Barricade Manual.
l. No street within the Project area may be closed to through traffic
or to local emergency traffic without prior, written approval of the Town Engineer. Written
approval may be given if sufficient time exists to allow for notification of the public at least two
days in advance of such closing. Partial closure of streets within the Project shall be done in
strict conformity with the Town Engineer’s written directions.
m. Caution should be used when excavating near intersections with
traffic signal underground cable. Contractor shall notify the Town Engineer 24 hours in advance
of any work at such intersections. The Contractor shall install and maintain temporary overhead
traffic signal cable as specified by the Town Engineer when underground conduit is to be
severed by excavations at intersections. The Contractor shall provide an off-duty uniformed
police officer to direct traffic while the traffic signal is turned off and the wiring is transferred.
All damaged or modified traffic signal overhead and underground items shall be repaired and
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restored to the Town Engineer’s satisfaction. Magnetic detector loops shall, under no
circumstances, be spliced.
n. The Contractor shall accommodate local access to adjacent
properties in accordance with the specification set forth below.
o. Where crossings of existing pavement occurs, no open trenches
shall be permitted overnight, but plating may be permitted if conditions allow, as determined by
the Town Engineer or his authorized representative in his sole discretion. If plates cannot be
used, crossings shall either be back-filled or the Contractor shall provide a detour.
1.11 Indemnification. To the fullest extent permitted by law, the Contractor
shall defend, indemnify and hold harmless the Town, its agents, representatives, officers,
directors, officials and employees from and against all claims, damages, losses and expenses
(including but not limited to attorneys' fees, court costs and the cost of appellate proceedings)
relating to, arising out of, or alleged to have resulted from the acts, errors, mistakes, omissions,
work or services of the Contractor, its employees, agents, or any tier of subcontractors in the
performance of this Contract. Contractor’s duty to defend, hold harmless and indemnify the
Town, its agents, representatives, officers, directors, officials and employees shall arise in
connection with any claim, damage, loss or expense that is attributable to bodily injury, sickness,
disease, death, or injury to, impairment or destruction of property, including loss of use resulting
therefrom, caused by any acts, errors, mistakes, omissions, work or services in the performance
of this Contract of any employee of the Contractor or any tier of subcontractor or any other
person for whose acts, errors, mistakes, omissions, work or services the Contractor may be
legally liable. The amount and type of insurance coverage requirements set forth below will in
no way be construed as limiting the scope of the indemnity in this paragraph.
1.12 Insurance Representations and Requirements.
a. General:
i. Insurer Qualifications. Without limiting any obligations or
liabilities of Contractor, Contractor shall purchase and maintain, at its own
expense, hereinafter stipulated minimum insurance with insurance companies
duly licensed by the State of Arizona with an AM Best, Inc. rating of A- or above
with policies and forms satisfactory to the Town. Failure to maintain insurance as
specified herein may result in termination of this Contract at the Town’s option.
ii. No Representation of Coverage Adequacy. By requiring
insurance herein, the Town does not represent that coverage and limits will be
adequate to protect Contractor. The Town reserves the right to review any and all
of the insurance policies and/or endorsements cited in this Contract but has no
obligation to do so. Failure to demand such evidence of full compliance with the
insurance requirements set forth in this Contract or failure to identify any
insurance deficiency shall not relieve Contractor from, nor be construed or
deemed a waiver of, its obligation to maintain the required insurance at all times
during the performance of this Contract.
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iii. Additional Insured. All insurance coverage and self
insured retention or deductible portions, except Workers’ Compensation
insurance and Professional Liability insurance, if applicable, shall name, to the
fullest extent permitted by law for claims arising out of the performance of this
Contract, the Town, its agents, representatives, officers, directors, officials and
employees as Additional Insured as specified under the respective coverage
sections of this Contract.
iv. Coverage Term. All insurance required herein shall be
maintained in full force and effect until all work or services required to be
performed under the terms of this Contract are satisfactorily performed,
completed and formally accepted by the Town, unless specified otherwise in this
Contract.
v. Primary Insurance. Contractor’s insurance shall be primary
insurance with respect to performance of this Contract and in the protection of the
Town as an Additional Insured.
vi. Claims Made. In the event any insurance policies required
by this Contract are written on a “claims made” basis, coverage shall extend,
either by keeping coverage in force or purchasing an extended reporting option,
for three years past completion and acceptance of the Work or services. Such
continuing coverage shall be evidenced by submission of annual Certificates of
Insurance citing applicable coverage is in force and contains the provisions as
required herein for the three-year period.
vii. Waiver. All policies, including Workers’ Compensation
insurance, shall contain a waiver of rights of recovery (subrogation) against the
Town, its agents, representatives, officials, officers and employees for any claims
arising out of the work or services of Contractor. Contractor shall arrange to have
such subrogation waivers incorporated into each policy via formal written
endorsement thereto.
viii. Policy Deductibles and or Self Insured Retentions. The
policies set forth in these requirements may provide coverage that contains
deductibles or self-insured retention amounts. Such deductibles or self-insured
retention shall not be applicable with respect to the policy limits provided to the
Town. Contractor shall be solely responsible for any such deductible or self-
insured retention amount. The Town, at its option, may require Contractor to
secure payment of such deductible or self-insured retention by a surety bond or
irrevocable and unconditional letter of credit.
ix. Use of Subcontractors. If any work under this Contract is
subcontracted in any way, Contractor shall execute written agreement with
Subcontractor containing the indemnification provisions set forth in Section 1.11
above and insurance requirements set forth herein protecting the Town and the
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Contractor. Contractor shall be responsible for executing the agreement with
Subcontractor and obtaining certificates of insurance verifying the insurance
requirements.
x. Evidence of Insurance. Prior to commencing any work or
services under this Contract, Contractor shall furnish the Town with certificate(s)
of insurance, or formal endorsements as required by this Contract, issued by
Contractor’s insurer(s) as evidence that policies are placed with acceptable
insurers as specified herein and provide the required coverages, conditions and
limits of coverage specified in this Contract and that such coverage and provisions
are in full force and effect. If a certificate of insurance is submitted as verification
of coverage, the Town shall reasonably rely upon the certificate of insurance as
evidence of coverage but such acceptance and reliance shall not waive or alter in
any way the insurance requirements or obligations of this Contract. Such
certificates shall identify the Contract work number and be sent to the Town
Engineer. If any of the above-cited policies expire during the life of this Contract,
it shall be Contractor’s responsibility to forward renewal certificates within ten
days after the renewal date containing all the aforementioned insurance
provisions. Additionally certificates of insurance submitted without referencing a
Contract number will be subject to rejection and returned or discarded.
Certificates of insurance shall specifically include the following provisions:
(1) The Town, its agents, representatives, officers,
directors, officials and employees are Additional Insureds as follows:
(a) Commercial General Liability - Under
Insurance Services Office, Inc., (“ISO”) Form CG 20 10 11 85 or
equivalent.
(b) Auto Liability - Under ISO Form CA 20 48
or equivalent.
(c) Excess Liability - Follow Form to
underlying insurance.
(2) Contractor’s insurance shall be primary insurance as
respects performance of the Contract.
(3) All policies, including Workers’ Compensation,
waive rights of recovery (subrogation) against Town, its agents, representatives,
officers, officials and employees for any claims arising out of work or services
performed by Contractor under this Contract.
(4) A 30-day advance notice cancellation provision. If
ACORD certificate of insurance form is used, the phrases in the cancellation
provision “endeavor to” and “but failure to mail such notice shall impose no
obligation or liability of any kind upon the company, its agents or representatives”
669417.1
shall be deleted. Certificate forms other than ACORD form shall have similar
restrictive language deleted.
b. Required Insurance Coverage:
i. Commercial General Liability. Contractor shall maintain
“occurrence” form Commercial General Liability insurance with an unimpaired
limit of not less than $1,000,000 for each occurrence, $2,000,000 Products and
Completed Operations Annual Aggregate and a $2,000,000 General Aggregate
Limit. The policy shall cover liability arising from premises, operations,
independent contractors, products-completed operations, personal injury and
advertising injury. Coverage under the policy will be at least as broad as ISO
policy form CG 00 010 93 or equivalent thereof, including but not limited to,
separation of insured’s clause. To the fullest extent allowed by law, for claims
arising out of the performance of this Contract, the Town, its agents,
representatives, officers, officials and employees shall be cited as an Additional
Insured under ISO, Commercial General Liability Additional Insured
Endorsement form CG 20 10 11 85, or equivalent, which shall read “Who is an
Insured (Section II) is amended to include as an insured the person or
organization shown in the Schedule, but only with respect to liability arising out
of “your work” for that insured by or for you.” If any Excess insurance is utilized
to fulfill the requirements of this paragraph, such Excess insurance shall be
“follow form” equal or broader in coverage scope than underlying insurance.
ii. Professional Liability. If this Contract is the subject of any
professional services or work, or if Contractor engages in any professional
services or work adjunct or residual to performing the work under this Contract,
Contractor shall maintain Professional Liability insurance covering errors and
omissions arising out of the work or services performed by Contractor, or anyone
employed by Contractor, or anyone for whose acts, mistakes, errors and omissions
Contractor is legally liable, with an unimpaired liability insurance limit of
$1,000,000 each claim and $2,000,000 all claims. In the event the Professional
Liability insurance policy is written on a “claims made” basis, coverage shall
extend for three years past completion and acceptance of the work or services, and
Contractor shall be required to submit certificates of insurance evidencing proper
coverage is in effect as required above.
iii. Vehicle Liability. Contractor shall maintain Business
Automobile Liability insurance with a limit of $1,000,000 each occurrence on
Contractor’s owned, hired and non-owned vehicles assigned to or used in the
performance of the Contractor’s work or services under this Contract. Coverage
will be at least as broad as ISO coverage code “1” “any auto” policy form CA 00
01 12 93 or equivalent thereof. To the fullest extent allowed by law, for claims
arising out of the performance of this Contract, the Town, its agents,
representatives, officers, directors, officials and employees shall be cited as an
Additional Insured under ISO Business Auto policy Designated Insured
Endorsement form CA 20 48 or equivalent. If any Excess insurance is utilized to
669417.1
fulfill the requirements of this paragraph, such Excess insurance shall be “follow
form” equal or broader in coverage scope than underlying insurance.
iv. Workers’ Compensation Insurance. Contractor shall
maintain Workers’ Compensation insurance to cover obligations imposed by
federal and state statutes having jurisdiction of Contractor’s employees engaged
in the performance of work or services under this Contract and shall also maintain
Employers Liability Insurance of not less than $500,000 for each accident,
$500,000 disease for each employee and $1,000,000 disease policy limit.
c. Certificates of Insurance. Prior to commencing the Work under
this Contract, Contractor shall furnish the Town with certificates of insurance, or formal
endorsements as required by this Contract, issued by Contractor’s insurer(s), as evidence that
policies providing the required coverages, conditions and limits required by this Contract are in
full force and effect. Unless otherwise specified in this Contract, in the event any insurance
policy(ies) required by this Contract is(are) written on a “claims made” basis, coverage shall
extend for two years past completion and acceptance of the Contractor’s work or services and as
evidenced by annual certificates of insurance. If a policy does expire during the life of the
Contract, a renewal certificate must be sent to the Town 30 days prior to the expiration date. All
certificates of insurance required by this Contract shall be identified with a bid serial number and
title. A $25.00 administrative fee shall be assessed for all certificates received without the
appropriate bid serial number and title.
d. Cancellation and Expiration Notice: Insurance required herein
shall not expire, be canceled, or materially changed without 30 days prior written notice to the
Town.
1.13 Performance Bond. The Contractor shall be required to furnish non-
revocable security binding the Contractor to provide faithful performance of the Contract in the
amount of 100% of the total Contract price payable to the Town. Performance security shall be
in the form of a performance bond, certified check or cashier’s check. This security must be in
the possession of the Town within the time specified or ten days after notice of award if no
period is specified. If the Contractor fails to execute the security document as required, the
Contractor may be found in default and the Contract terminated by the Town. In case of default
the Town reserves all rights. All performance bonds shall be executed on COA Form 02-03
attached hereto as Exhibit I and incorporated herein by this reference, duly executed by the
Bidder as Principal and having as Surety thereon a Surety company approved by the Town and
holding a Certificate of Authority to transact surety business in the State of Arizona, by the
Arizona Department of Insurance. Individual sureties are unacceptable. All Insurers and
Sureties shall have at the time of submission of the proposal and A.M. Best’s Key Rating Guide
of “A-” or better as currently listed in the most recent Best Key Guide, published by the A.M.
Best Company.
1.14 Payment Bond. The Contractor shall be required to furnish non-revocable
security for the protection of all persons supplying labor and material to the Contractor or any
subcontractor for the performance of any work related to the Contract. Payment security shall be
in the amount of 100% of the total Contract price and be payable to the Town. Payment security
669417.1
shall be in the form of a payment bond, certified check or cashier’s check. All payment bonds
shall be executed on a COA Form 02-04 attached hereto as Exhibit J and incorporated herein by
this reference, duly executed by the Bidder as Principal and having as Surety thereon a Surety
company approved by the Town and holding a Certificate of Authority to transact surety
business in the State of Arizona, by the Arizona Department of Insurance. Individual sureties are
unacceptable. All Insurers and Sureties shall have at the time of submission of the proposal and
A.M. Best’s Key Rating Guide of “A-” or better as currently listed in the most recent Best Key
Guide, published by the A.M. Best Company.
1.15 Affirmative Action Report. It is the policy of the Town that suppliers of
goods or services to the Town adhere to a policy of equal employment opportunity and
demonstrate an affirmative effort to recruit, hire, and promote regardless of race, color, religion,
gender, national origin, age or disability. On any Contract in excess of six months, the
Contractor shall provide an annual report to the Town highlighting its activities to comply with
this Section 1.15.
2. PERFORMANCE OF THE WORK.
2.1 Work Scheduling. Time is of the essence for this Contract. Contractor
shall comply with the Work Schedule set forth in the attached Exhibit G. The Work Schedule
includes the date for Substantial Completion of the Work. For purposes of this Contract, the
term “Substantial Completion” shall mean the date when construction is sufficiently complete in
accordance with the Scope of Work so that the Town can safely occupy and fully utilize the
Project, or a designated portion thereof, for the use for which it is intended. The Project shall not
be considered complete until the Town has signed the Contractor’s Notice of Final Acceptance,
attached hereto as Exhibit B. The Town may revise the Work Schedule during the course of the
Work. Contractor, to induce the Town to enter into this Contract, has and does hereby agree to
fully perform and complete the Work for the Contract Price within the Work Schedule.
2.2 Prosecution of the Work.
a. Contract Time. The Contractor shall commence work under the
Project in accordance with the Notice to Proceed attached hereto as Exhibit A. The Contractor
shall, at all times, during the continuance of the Contract, prosecute the work with such force and
equipment as is sufficient to complete all Work within the time specified.
b. Timely Completion. The Contractor shall prosecute the Work so
that the portion of the Work completed at any point in time shall be not less than as required by
the Work Schedule. If the delay is an Inexcusable Delay, as defined below, the Contractor shall
prepare a recovery schedule for the Town’s review and approval, showing how the Contractor
will compensate for the delays and achieve Substantial Completion by the date(s) shown on the
Work Schedule. If the Contractor is unable to demonstrate how it will overcome Inexcusable
Delays, the Town may order the Contractor to employ such extraordinary measures as are
necessary to bring the Work into conformity with the Substantial Completion date(s) set forth
therein, the costs of which shall be included as part of the cost of the Work. If the delay is an
Excusable Delay, as defined below, the Town shall either (i) authorize an equitable extension in
the Work Schedule to account for such delay, and equitably adjust the contract sum on account
669417.1
of such delay or (ii) request that the Contractor prepare a recovery schedule showing how (if
possible) the Contractor can achieve Substantial Completion by the applicable date shown on the
Work Schedule, and equitably adjust the contract sum in accordance with the Change Order
provisions of this Contract on account of any extraordinary activities required of the Contractor
on account of such recovery schedule.
c. Extensions of Time.
i. An extension in the scheduled date of Substantial
Completion will only be granted in the event of Excusable Delays affecting the
Work. The Contractor shall be entitled to general condition costs and extra costs
related to the excusable delay for idle labor, equipment inefficiency and lost
productivity of the performance of the Work. The Contractor must submit
evidence reasonably satisfactory to the Town substantiating such costs. Such
adjustment to the contract sum and Substantial Completion date shall be issued in
a Change Order.
ii. To the extent any of the following events results in an
actual delay in the Work, such shall constitute an “Excusable Delay” (to the
extent not set forth below, a delay will be considered an “Inexcusable Delay”):
(1) Delays resulting from Force Majeure.
(2) Differing, unusual or concealed site conditions that
could not reasonably have been anticipated by the Contractor in preparing the
Schedule, including, without limitation, archaeological finds and soil conditions
(including rock or other geological conditions), underground foundations,
abandoned utility lines and water conditions.
(3) Delays resulting from the existence or discovery of
Hazardous Materials on the Site not brought to the site by the Contractor.
(4) Delays resulting from changes in applicable laws
occurring after the date of execution of this Contract.
(5) Delays occurring due to the acts or omissions of the
Town and those within the control of the Town.
(6) Delays occurring due to the acts or omissions of a
utility, so long as Contractor has coordinated with the utility causing the delay and
the delay occurs despite reasonable steps taken by Contractor to avoid the delay.
(7) Delays resulting from weather conditions which
make it unreasonable to perform the Work in accordance with the Schedule.
iii. In order to obtain an extension of time due to an Excusable
Delay, the Contractor shall comply with the following requirements. The
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Contractor shall notify the Town of the Excusable Delay as soon as practicable,
but in no event more than seven Days after the Contractor becomes aware of the
occurrence of the Excusable Delay. Such notice shall describe the Excusable
Delay and shall state the approximate number of Days the Contractor expects to
be delayed. After the cessation of the Excusable Delay, the Contractor shall
notify the Town of the number of Days the Contractor believes that its activities
were in fact delayed by the Excusable Delay. In the event that the delay arises as
a result of a Change Order request by the Town, the request for an extension of
time contained in the resulting Change Order proposal shall be deemed sufficient
for purposes of this subsection.
iv. Within ten days after cessation of an event giving rise to
either an Excusable Delay or Inexcusable Delay, the parties will use good faith
efforts to agree on the extent to which the Work has been delayed and whether the
delay is an Excusable Delay or an Inexcusable Delay. In the absence of
agreement between the parties as to the then-current status of Excusable Delays
and Inexcusable Delays, the Town will provide the Contractor with written notice
of Town’s determination of the respective number of Days of Excusable Delay
and/or Inexcusable Delay within ten days after receipt by the Town of the
Contractor’s written request for such determination. The Contractor shall not,
however, deem an issuance by the Town of such a determination to be a
concurrence of the matters set forth therein, and the Contractor may invoke the
dispute resolution procedures set forth in Section 4 below with respect to such
determination.
d. Concurrent delays. To the extent the Contractor is entitled to an
extension of time due to an Excusable Delay, but the performance of the Work would have been
suspended, delayed or interrupted by the fault or neglect of the Contractor or by an Inexcusable
Delay, the Contractor shall not be entitled to any additional costs for the period of such
concurrency.
2.3 Liquidated Damages. It is expressly understood that should Contractor
fail to complete the Work covered hereby within the Contract Time, the Contractor agrees to
pay and shall pay to the Town upon request therefore for each calendar day of delay beyond the
original or revised scheduled time of completion of Contractor’s work as liquidated damages,
and not as a penalty, the following liquidated damages shall be in the amount equal to $400 per
day for each calendar day of delay.
a. If the Contract is not terminated, the Contractor shall continue
performance and be liable to the Town for the liquidated damages until the Work is complete.
b. In the event the Town exercises its right of termination, the
Contractor shall be liable to the Town for any excess costs and, in addition, for liquidated
damages until such time the Town may reasonably obtain delivery or performance of similar
services.
669417.1
2.4 Termination by the Town for Cause.
a. If the Contractor refuses or fails to supply sufficient properly
skilled staff or proper materials, or disregards laws, ordinances, rules, regulations, or orders of
any public authority jurisdiction, or otherwise substantially violates or materially breaches any
term or provision of this Contract, and such nonperformance or violation continues without cure
for 15 days after the Contractor receives written notice of such nonperformance or violation from
the Town, then the Town may, without prejudice to any right or remedy otherwise available to
the Town, terminate this Contract.
b. Upon termination of this Contract by the Town, the Town shall be
entitled to furnish or have furnished the services to be performed hereunder by the Contractor by
whatever method the Town may deem expedient. Also, in such case, the Contractor shall not be
entitled to receive any further payment until completion of the Work; and the total compensation
to the Contractor under this Contract shall be the amount that is equitable under the
circumstances. If the Town and the Contractor are unable to agree on the amount to be paid
under the foregoing sentence, the Town shall fix an amount, if any, that it deems appropriate in
consideration of all of the circumstances surrounding such termination, and shall make payment
accordingly. The Contractor may dispute the Town’s assessment of the termination amount
pursuant to the dispute resolution process set forth in this Contract.
c. Upon the appointment of a receiver for the Contractor, or if the
Contractor makes a general assignment for the benefit of creditors, the Town may terminate this
Contract, without prejudice to any right or remedy otherwise available to the Town, upon giving
three working days’ written notice to the Contractor. If an order for relief is entered under the
bankruptcy code with respect to the Contractor, the Town may terminate this Contract by giving
three working days’ written notice to the Contractor unless the Contractor or the trustee
completes all of the following:
i. Promptly cures all breaches within such three-day period.
ii. Provides adequate assurances of future performance.
iii. Compensates the Town for actual pecuniary loss resulting
from such breaches.
iv. Assumes the obligations of the Contractor within the
established time limits.
2.5 Termination by the Town for Convenience. The Town may, upon 30
days’ written notice to the Contractor, terminate this Contract, in whole or in part, for the
convenience of the Town without prejudice to any right or remedy otherwise available to the
Town. Upon receipt of such notice, the Contractor shall immediately discontinue all services
affected unless such notice directs otherwise. In the event of a termination for convenience of
the Town, the Contractor’s sole and exclusive right and remedy shall be payment for all work
performed through the date of termination. The Contractor shall not be entitled to be paid any
669417.1
amount as profit for unperformed services or consideration for the termination of convenience by
the Town.
2.6 Suspension by the Town for Convenience.
a. The Town may order the Contractor in writing to suspend, delay or
interrupt all or any part of the Work without cause for such period of time as the Town may
determine to be appropriate for its convenience.
b. Adjustments caused by suspension, delay or interruption shall be
made for increases in the applicable contract sum and/or the date(s) of Substantial Completion.
No adjustment shall be made if the Contractor is or otherwise would have been responsible for
the suspension, delay or interruption of the Work, or if another provision of this Contract is
applied to render an equitable adjustment.
2.7 Additional Materials and/or Overtime. Contractor expressly agrees that if
overtime or additional workers or materials are necessary to meet the Work Schedule, that such
overtime will be performed or additional workers or materials will be procured by the
Contractor, and the additional expense thereof shall be borne by Contractor unless the delay
requiring overtime shall have been occasioned directly by the Town, in which event Contractor
shall be entitled to compensation for such overtime work.
2.8 No Damage for Delay by the Town. Contractor shall adjust its operations
to conform to any progress schedule changes and hereby waives and releases the Town from any
liability for damages or expenses which may be caused to or sustained by Contractor by reason
of such changes or by reason of delays in the Work, whether caused in whole or in part by
conduct on the part of the Town, including without limitation, any breach of this Contract or
delays by other contractors or subcontractors. Contractor’s exclusive remedy in event of delay
by the Town shall be an extension of time hereunder to complete the Work.
2.9 Proposal Quantities. It is expressly understood and agreed by the parties
hereto that the quantities of the various classes of work to be done and the material to be
furnished under this Contract, which have been estimated as stated in the Bidder’s Submission,
are only approximate and are to be used solely for the purpose of comparing, on a consistent
basis, the Bidder’s Submission presented for the Work under this Contract. The Contractor
further agrees that the Town shall not be held responsible if any of the quantities shall be found
to be incorrect and the Contractor will not make any claim for damages or for loss of profits
because of a difference between the quantities of the various classes of Work as estimated and
the Work actually done. If any error, omission or misstatement is found to occur in the estimated
quantities, the same shall not (i) invalidate this Contract or the whole or any part of the Work in
accordance herewith and for the prices herein agreed upon and fixed therefore, (ii) excuse
Contractor from any of the obligations or liabilities hereunder or (iii) entitle Contractor to any
damage or compensation except as may be provided in this Contract.
2.10 Risk of Loss. Contractor shall assume the risk of loss occasioned by fire,
theft or other damage to materials, machinery, apparatus, tools and equipment relating to the
Work prior to actual installation in final place on the Project and acceptance by the Town.
669417.1
Contractor shall be responsible for damage to the materials, machinery, apparatus, tools,
equipment and property of the Town and other contractors resulting from the acts or omissions
of its subcontractors, employees, agents, representatives sub-contractors, and to pay the full costs
of repair or replacement of any said damage.
2.11 Character and Status of Workers. Only skilled foremen and workers shall
be employed on work requiring special qualifications. When required by the Town’s Engineer,
the Contractor shall discharge any person who is, in the opinion of the Town’s Engineer,
disorderly, dangerous, insubordinate, incompetent or otherwise objectionable. The Contractor
shall indemnify and hold harmless the Town from and against damages or claims for
compensation that may occur in the enforcement of this section. The Contractor shall be
responsible for assuring the legal working status of its employees and its subcontractor’s
employees. The Contractor agrees that once assigned to work under this Contract, key personnel
shall not be removed or replaced without written notice to the Town. If key personnel are not
available for work under this Contract for a continuous period exceeding 30 calendar days, or are
expected to devote substantially less effort to the Work than initially anticipated, the Contractor
shall immediately notify the Town and shall, subject to the concurrence of the Town, replace
such personnel with personnel of substantially equal ability and qualifications.
2.12 Work Methods. The methods, equipment and appliances used on the
Work shall be such as will produce a satisfactory quality of Work, and shall be adequate to
complete the Contract within the time limit specified. Except as is otherwise specified in this
Contract, the Contractor’s procedure and methods of construction may, in general, be of its own
choosing, provided such methods (i) follow best general practice and (ii) are calculated to secure
results which will satisfy the requirements of this Contract. The Work covered by this Contract
shall be carefully laid out in advance and performed in a manner to minimize interference with
normal operation and utilization of the Town’s right-of-way. The Contractor shall exercise
caution during the course of this Work to avoid damage to all known existing or possible
unknown existing underground utilities. It shall conduct its operations in such a manner as to
avoid injury to its personnel and to avoid damage to all utilities. Any damage done will be
repaired without delay and at the expense of the Contractor.
2.13 Drawings, Samples and Substitution of Materials. Contractor shall
furnish, within three business days following request therefore by the Town, detailed drawings of
the Work, samples of materials and other submittals required for the performance or coordination
of the Work. Substitutions shall be equal or superior to materials specified in the Contract
Documents and shall be clearly identified on submittals as “proposed substitutions”. Contractor
shall be fully responsible for the adequacy, completeness and promptness of all such submittals.
Materials shall not be furnished to the jobsite unless same is in strict compliance with the
specifications or otherwise approved in writing by the Town. Approval by the Town shall not
relieve Contractor of full responsibility for compliance with scope, intent and performance in
accordance with this Contract.
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2.14 Outdoor Construction Time Restrictions. Construction will be restricted
as listed in the following table:
Construction Type April 2 –
September 29
September 30 –
April 1
A Concrete Work 5:00 a.m. to 7:00
p.m.
6:00 a.m. to 7:00
p.m.
B Other Construction (within 500 feet of residential
area)
6:00 a.m. to 7:00
p.m.
7:00 a.m. to 7:00
p.m.
C Construction Work (more than 500 feet of
residential area)
5:00 a.m. to 7:00
p.m.
5:00 a.m. to 7:00
p.m.
2.15 Survey Control Points. Existing survey markers (either brass caps or iron
pipes) shall be protected by the Contractor or removed and replaced under direct supervision of
the Town Engineer or his authorized representative. Survey monuments shall be constructed to
the requirements of MAG Specifications, Section 405, and Standard Details. Lot corners shall
not be disturbed without knowledge and consent of the property owner. The Contractor shall
replace benchmarks, monuments or lot corners moved or destroyed during construction at no
expense to the Town. Contractor and its sureties shall be liable for correct replacement of
disturbed survey benchmarks except where the Town elects to replace survey benchmarks using
its own forces.
2.16 Protection of Finished or Partially Finished Work. The Contractor shall
properly guard and protect all finished or partially finished work and shall be responsible for the
same until the entire Contract is completed and accepted by the Town Engineer. The Contractor
shall turn over the entire Work in full accordance with this Contract before final settlement shall
be made.
2.17 Stockpile of Materials.
a. The Contractor may, if approved by the Town Engineer, place or
stockpile materials in the public right-of-way provided such materials do not prevent access to
adjacent properties or prevent compliance with traffic regulations.
b. Traffic shall not be required to travel over stockpiled materials and
proper dust control shall be maintained.
2.18 Excess Materials. When excavations are made, resultant loose earth shall
be (i) utilized for filling by compacting in place or (ii) disposed of off-site. Excess or unsuitable
material, broken asphaltic concrete and broken portland cement concrete excavated from the
right-of-way shall be removed from the project and disposed of by the Contractor. Disposal of
material within the Town Limits or Planning Area must be approved by the Town Engineer or
his authorized representative. Waste material shall not be placed on private property without
express permission of the property owner. The Contractor shall, at all times, keep the premises
free from accumulation of waste materials or rubbish caused by its operations. At the
completion of the work, Contractor shall remove all equipment, tools and surplus materials, and
shall completely clean the premises, removing and disposing of all debris and rubbish and
cleaning all stains, spots, marks, dirt, smears or other blemishes. When the Work premises are
669417.1
turned over to the Town, they shall be thoroughly clean and ready for immediate use. Clean-up
shall include removal of all excess pointing mortar materials within pipes and removal of
oversized rocks and boulders left after finish grading. The Contractor shall provide for the legal
disposal of all waste products and debris and shall make necessary arrangements for such
disposal.
2.19 Dust Control and Water. Contractor shall implement dust control
measures in accordance with the requirements of the “Maricopa County Health Department Air
Pollution Control Regulations.” Specifically, Regulation II, Rule 21, subparagraph C and
Regulation III, Rule 310 shall be rigidly observed and enforced. Water or other approved dust
palliative in sufficient quantities shall be applied during all phases of construction involving
open earthwork to prevent unnecessary discharge of dust and dirt into the air. The Contractor
shall be required to obtain the necessary permit and all pertinent information from the Maricopa
County Air Pollution Control Bureau. The Contractor shall keep suitable equipment on hand at
the job site for maintaining dust control on the project streets, and shall employ sufficient labor,
materials and equipment for that purpose at all times during the Project to the satisfaction of the
Town Engineer. Watering shall conform to the provisions of Section 225 of the MAG
Specifications. The cost of watering will be included in the Contractor Bid for the construction
operation to which such watering is incidental or appurtenant. Installation and removal of fire
hydrant meters should be scheduled at least 48 hours in advance. A $350 deposit and a $100
installation fee are required for each meter. The cost of the water is at the prevailing rate.
2.20 Temporary Sanitary Facilities. The Contractor shall provide ample toilet
facilities with proper enclosures for the use of workmen employed on the Work site. Toilet
facilities shall be installed and maintained in conformity with all applicable state and local laws,
codes, regulations and ordinances. They shall be properly lit and ventilated, and kept clean at all
times. Adequate and satisfactory drinking water shall be provided at all times and under no
circumstances and under no conditions will the use of common cups be permitted. The
Contractor must supply sanitary drinking cups for the benefit of all employees.
2.21 Electric Power, Water and Telephone. Unless otherwise specified, the
Contractor shall make its own arrangements for electric power, water and telephone. Subject to
the convenience of the utility, it may be permitted to connect to existing facilities where
available, but Contractor shall meter and bear the cost of such power or water, and installation
and disconnect of such power, water and telephone services.
2.22 Energized Aerial Electrical Power Lines. Utility companies may maintain
energized aerial electrical power lines in the immediate vicinity of this Project. Contractor shall
not presume any such lines to be insulated. Construction personnel working in proximity to
these lines may be exposed to an extreme hazard from electrical shock. Contractor, its
employees and all other construction personnel working on this Project must be warned of the
danger and instructed to take adequate protective measures, including maintaining a minimum
ten feet clearance between the lines and all construction equipment and personnel. (See, OSHA
Std. 1926-550 (a) 15). As an additional safety precaution, Contractor shall call the affected
utility companies to arrange, if possible, to have these lines de-energized or relocated when the
Work reaches their immediate vicinity. The cost of such temporary arrangements shall be borne
by the Contractor. Contractor shall account for the time necessary to cause such utility
669417.1
disconnection in the preparation of its Bid. Electrical utility companies may maintain energized
underground electrical power lines in the immediate vicinity of this Project. These power lines
represent an extreme hazard of electrical shock to any construction personnel or equipment
coming in contact with them. Arizona law requires all parties planning excavations in public
rights-of-way to contact all utility firms for locations of their underground facilities.
Contractors, their employees, and all other personnel working near any underground power lines
must be warned to take adequate protective measure. (See, OSHA Std. 1926-651 (A)).
2.23 Site Clean Up. Contractor shall at all times, but not less than daily unless
otherwise agreed by Town, keep the premises on which the Work is being performed clean and
free from accumulation of any waste materials, trash, debris and excess dirt, and at all times shall
remove Contractor’s implements, machinery, tools, apparatus and equipment from the jobsite
when not needed on the jobsite. Should the Town find it necessary in its opinion to employ help
to clean up, remove or store any of the foregoing or failure of Contractor to do so, the expense
thereof shall be charged to Contractor. Verbal notice from a Town representative on clean-up or
removal is considered adequate notice hereunder, and failure to conform with his/her request
within 24 hours thereof will be construed as a breach of this Contract by the Contractor and such
charges will be made against Contractor’s account as are necessary to accomplish the clean-up or
removal. The cost of clean up, removal or storage by the Town, if not deducted by the Town
from monies due Contractor, shall be paid by Contractor within five business days of written
demand by the Town.
2.24 Use of The Site. Contractor shall at all times comply fully with all laws,
orders, citations, rules, regulations, standards and statutes with respect to occupational health and
safety, the handling and storage of hazardous materials, accident prevention, safety equipment
and practices, including any accident prevention and safety program of the Town; provided,
however, that the Town shall not be required to impose any safety requirements or administer
any such programs and the review or requirement of any safety plan by the Town shall not be
deemed to release Contractor or in any way diminish its liability, by way of indemnity or
otherwise, as assumed by it under this Contract. Contractor shall conduct inspections regularly
to determine that safe working conditions and equipment exist and accepts sole responsibility for
providing a safe place to work for its employees and employees of its subcontractors, laborers
and suppliers of material and equipment, for adequacy of and required use of all safety
equipment and for compliance herewith. When so ordered, Contractor shall stop any part of the
Work that the Town deems unsafe until corrective measures satisfactory to the Town have been
taken. Should Contractor neglect to adopt such corrective measures, the Town may do so and
deduct the cost from payments due Contractor. Contractor shall timely submit copies of all
accident or injury reports to the Town.
2.25 Public Information and Notification. The Contractor shall submit a public
information and notification plan for this Project (the “Notification Plan”) to the Town at the first
pre-construction meeting held prior to start of construction. The Notification Plan shall include,
at a minimum, the items set forth in this Section 2.25; provided, however, that the Town
Engineer may waive any portion of the requirements of this Section 2.25 upon a written
determination that the Project scope does not warrant such notification. Contractor shall provide
Project information to affected residents and homeowners’ associations prior to and throughout
the Project’s duration. The Contractor shall use the Notification Plan to inform the local citizens,
669417.1
businesses and Town officials, not less than five business days in advance, of (i) necessary
operations that create high noise levels, (ii) street closures, (iii) detour locations, (iv) haul routes
and material delivery routes and (v) disruption of bus routes, mail routes and other delivery/pick-
up routes.
a. Neighborhood Notification: Prior to the start of any work on the
Project, the Contractor shall distribute a preliminary “Dear Neighbor” letter (8-1/2”x11”) to all
businesses, property owners and residents within 600 feet of any portion of this Project. This
“Dear Neighbor” letter shall include, at a minimum, the following information:
i. Contractor’s name, business telephone number and the 24-
hour “Hot Line” telephone number for this Project
ii. Name of Contractor’s Project Manager
iii. Name of Contractor’s Project Superintendent
iv. Brief description of the Project
v. Construction schedule, including anticipated work hours
vi. Anticipated lane restrictions, including the expected
duration thereof
vii. Name of Town’s Contract Administrator
viii. Name of the Town’s Engineer
The Town Engineer shall provide the Contractor with a distribution list for this “Dear Neighbor”
letter. Contractor shall (i) ensure that the letter is distributed to all persons and businesses
indicated on the list provided by the Town Engineer and (ii) provide the Town Engineer with a
copy of the letter sent and sufficient proof of mailing. Subsequent to the aforementioned, the
Contractor shall distribute bi-monthly construction progress updates, including construction
schedule and any additional information the Town Engineer deems important as a result of
construction activities, to all persons and businesses included on the aforementioned distribution
list. At the request of the Town Engineer, Contractor may be required to distribute additional
public notifications. At the end of construction a final “Dear Neighbor” letter shall be distributed
to the persons and businesses on the aforementioned distribution list highlighting the
Contractor’s and the Town’s appreciation for their patience during construction of the Project.
b. Project Signs: The Contractor shall furnish and install at least two
Project signs, unless otherwise directed by the Town Engineer, not less than five business days
before beginning construction, at locations determined by the Town Engineer, to inform the
public of the forthcoming Project, construction dates and 24-Hour Hotline number. The
Contractor shall maintain the signs as necessary and update the information as directed by the
Town Engineer. At the completion of the project, the Contractor shall remove and dispose of the
signs. The Project signs shall be fabricated as directed by the Town Engineer.
669417.1
c. 24-Hour Project Hotline: The Contractor shall be required to
furnish a private 24-hour telephone line to be used solely for receiving incoming calls from local
citizens or businesses with questions or complaints concerning Project construction operations or
procedures (the “Hotline”). The Contractor shall include this Hotline telephone number on all
public information distributed throughout the duration of the Project. Contractor shall ensure
that Contractor personnel man the Hotline during all hours that there is any work being
performed on this Project; the Hotline shall be answered by a live answering service during all
other hours. The Contractor shall maintain a log of incoming calls, responses and action taken
that shall be submitted to the Town Engineer weekly and upon request.
d. Public Meetings: The Contractor shall attend public meetings
deemed necessary by the Town Engineer.
e. Press Releases: The Contractor shall, at the request of the Town
Engineer, prepare press releases regarding the Project.
f. Payment for Public Notification: The Town will pay, based on
time and materials invoices, an amount not to exceed $10,000.00 for work performed in
accordance with the Notification Plan, which amount shall be included in the Price Sheet
attached hereto as part of Exhibit C. Work which is eligible for reimbursement includes: the
“Dear Neighbor” letters; bi-monthly progress reports; meetings with impacted businesses,
residents, schools, churches or other groups; scheduling newsletter when necessary (at least
monthly); temporary signs for local access; and maintaining the Hotline. The cost for the Project
signs, including installation, maintenance and all labor and materials shall be a non-pay item and
shall be considered incidental to the items of work. No payment will be made under this item for
any calendar day during which there are substantial deficiencies in compliance, as determined by
the Town Engineer. The Contractor shall submit a final report/evaluation of its Notification Plan
process performed for this Project. The report shall be submitted before the Contractor receives
final payment.
3. MISCELLANEOUS.
3.1 Gratuities. The Town may, by written notice to the Contractor, cancel this
Contract if it is found by the Town that gratuities, in the form of entertainment, gifts or
otherwise, were offered or given by the Contractor or any agent or representative of the
Contractor, to any officer or employee of the Town for the purpose of securing this Contract. In
the event this Contract is cancelled by the Town pursuant to this provision, the Town shall be
entitled, in addition to any other rights and remedies, to recover or withhold from the Contractor
an amount equal to 150% of the gratuity.
3.2 Applicable Law; Venue. In the performance of this Contract, Contractor
shall abide by and conform to any and all laws of the United States, State of Arizona and Town
of Fountain Hills, including but not limited to, federal and state executive orders providing for
equal employment and procurement opportunities, the Federal Occupational Safety and Health
Act and any other federal or state laws applicable to this Contract. This Contract shall be
669417.1
governed by the laws of the State of Arizona and suit pertaining to this Contract may be brought
only in courts in the State of Arizona.
3.3 Cancellation. This Contract is subject to the provisions of ARIZ. REV.
STAT. § 38-511; the Town may cancel this Contract without penalty or further obligations by the
Town or any of its departments or agencies if any person significantly involved in initiating,
negotiating, securing, drafting or creating this Contract on behalf of the Town or any of its
departments or agencies is, at any time while the Contract or any extension of the Contract is in
effect, an employee of any other party to the Contract in any capacity or a consultant to any other
party of the Contract with respect to the subject matter of the Contract.
3.4 Contract Amendments. This Contract may be modified only by a written
Contract Amendment approved by the Town Council and signed by persons duly authorized to
enter into contracts on behalf of the Town and the Contractor.
3.5 Provisions Required By Law. Each and every provision of law and any
clause required by law to be in the Contract will be read and enforced as though it were included
herein, and if through mistake or otherwise any such provision is not inserted, or is not correctly
inserted, then upon the application of either party, the Contract will forthwith be physically
amended to make such insertion or correction.
3.6 Severability. The provisions of this Contract are severable to the extent
that any provision or application held to be invalid by a Court of competent jurisdiction shall not
affect any other provision or application of the Contract which may remain in effect without the
invalid provision or application.
3.7 Relationship of the Parties. It is clearly understood that each party will act
in its individual capacity and not as an agent, employee, partner, joint venturer, or associate of
the other. An employee or agent of one party shall not be deemed or construed to be the
employee or agent of the other for any purpose whatsoever. The Contractor is advised that taxes
or Social Security payments will not be withheld from any Town payments issued hereunder and
that the Contractor should make arrangements to directly pay such expenses, if any.
3.8 Entire Agreement; Interpretation; Parol Evidence. This Contract
represents the entire agreement of the parties with respect to its subject matter, and all previous
agreements, whether oral or written, entered into prior to this Contract are hereby revoked and
superseded by this Contract. No representations, warranties, inducements or oral agreements
have been made by any of the parties except as expressly set forth herein, or in any other
contemporaneous written agreement executed for the purposes of carrying out the provisions of
this Contract. This Contract shall be construed and interpreted according to its plain meaning,
and no presumption shall be deemed to apply in favor of, or against the party drafting the
Contract. The parties acknowledge and agree that each has had the opportunity to seek and
utilize legal counsel in the drafting of, review of, and entry into this Contract.
3.9 Assignment; Delegation. No right or interest in this Contract shall be
assigned by Contractor without prior, written permission of the Town and no delegation of any
duty of Contractor shall be made without prior, written permission of the Town.
669417.1
3.10 Subcontracts. No subcontract shall be entered into by the Contractor with
any other party to furnish any of the material, service or construction specified herein without the
prior written approval of the Town. A Contractor acting as prime Contractor shall itemize in its
Bid all sub-contractors that shall be utilized on the Project. Any substitution of sub-contractors
by the Contractor must receive Town approval prior to such substitution and any cost savings
will be reduced from the Contractor’s bid amount. All subcontracts shall comply with Federal
and State laws and regulations which are applicable to the services covered by the subcontract
and shall include all the terms and conditions set forth herein which shall apply with equal force
to the subcontract as if the subcontractor were the Contractor referred to herein. The Contractor
is responsible for Contract performance whether or not subcontractors are used.
3.11 Rights and Remedies. No provision in this Contract shall be construed,
expressly or by implication, as waiver by the Town of any existing or future right and/or remedy
available by law in the event of any claim of default or breach of this Contract. The failure of
the Town to insist upon the strict performance of any term or condition of this Contract or to
exercise or delay the exercise of any right or remedy provided in this Contract, or by law, or the
Town’s acceptance of and payment for materials or services, shall not release the Contractor
from any responsibilities or obligations imposed by this Contract or by law, and shall not be
deemed a waiver of any right of the Town to insist upon the strict performance of this Contract.
3.12 Overcharges by Antitrust Violations. The Town maintains that, in
practice, overcharges resulting from antitrust violations are borne by the purchaser. Therefore, to
the extent permitted by law, the Contractor hereby assigns to the Town any and all claims for
such overcharges as to the goods and services used to fulfill the Contract.
3.13 Force Majeure.
a. Except for payment for sums due, neither party shall be liable to
the other nor deemed in default under this Contract if and to the extent that such party’s
performance of this Contract is prevented by reason of force majeure. The term “force majeure”
means an occurrence that is beyond the control of the party affected and occurs without its fault
or negligence. Without limiting the foregoing, force majeure includes acts of God; acts of the
public enemy; war; riots; strikes; mobilization; labor disputes; civil disorders; fire; floods;
lockouts, injunctions-intervention-acts, or failures or refusals to act by government authority; and
other similar occurrences beyond the control of the party declaring force majeure which such
party is unable to prevent by exercising reasonable diligence. The force majeure shall be deemed
to commence when the party declaring force majeure notifies the other party of the existence of
the force majeure and shall be deemed to continue as long as the results or effects of the force
majeure prevent the party from resuming performance in accordance with this Contract.
b. Force majeure shall not include the following occurrences:
i. Late delivery of equipment or materials caused by
congestion at a manufacturer’s plant or elsewhere, an oversold condition of the
market, inefficiencies or similar occurrences.
669417.1
ii. Late performance by a subcontractor unless the delay arises
out of a force majeure occurrence in accordance with this Section 3.13.
c. Any delay or failure in performance by either party hereto shall not
constitute default hereunder or give rise to any claim for damages or loss of anticipated profits if,
and to the extent that such delay or failure is caused by force majeure. If either party is delayed
at any time in the progress of the work by force majeure, then the delayed party shall notify the
other party in writing of such delay within 48 hours commencement thereof and shall specify the
causes of such delay in such notice. Such notice shall be hand delivered or sent via U.S. Mail,
Certified-Return Receipt and shall make a specific reference to this Section, thereby invoking its
provisions. The delayed party shall cause such delay to cease as soon as practicable and shall
notify the other party in writing. The time of completion shall be extended by written Contract
amendment for a period of time equal to the time that the results or effects of such delay prevent
the delayed party from performing in accordance with this Contract.
3.14 Right to Assurance. Whenever one party to this Contract in good faith has
reason to question the other party’s intent to perform it may demand that the other party give a
written assurance of its intent to perform. In the event that a demand is made and no written
assurance is given within five days, the demanding party may treat this failure as an anticipatory
repudiation of the Contract.
3.15 Right to Audit Records. The Town may, at reasonable times and places,
audit the books and records of the Contractor as related to this Contract.
3.16 Right to Inspect Plant. The Town may, at reasonable times, inspect the
part of the plant or place of business of the Contractor or subcontractor that is related to the
performance of this Contract.
3.17 Warranties. Contractor warrants to the Town that all materials and
equipment furnished shall be new unless otherwise specified and agreed by the Town and that all
Work shall be of first class quality, free from faults and defects and in conformance with the
Contract. If at any time within one year following the date of completion and acceptance of the
entire Project (or such longer period as may be provided under warranties for equipment or
materials): (a) any part of the materials furnished in connection with the Work shall be or
become defective due to defects in either labor or materials, or both, or (b) Contractor’s work or
materials, or both, are or were not in conformance with original or amended plans and
specifications, or supplementary or shop drawings, then the Contractor shall upon written notice
from the Town immediately replace or repair such defective or non-conforming material or
workmanship at no cost to the Town. Contractor further agrees to execute any special guarantees
as provided by the Contract or required by law. Contractor shall require similar guarantees from
all vendors and from all its subcontractors. Contractor further agrees, upon written demand of
the Town and during the course of construction, to immediately re-execute, repair or replace any
work that fails to conform to the requirements of the Contract, whether caused by faulty
materials or workmanship, or both. In the event Contractor shall fail or refuse to make such
change upon the Town’s written demand, the Town shall have the right to have such work re-
executed, repaired or replaced, to withhold from or back charge to Contractor all costs incurred
thereby.
669417.1
3.18 Inspection. All material and/or services are subject to final inspection and
acceptance by the Town. Materials and/or services failing to conform to the specifications of
this Contract will be held at Contractor’s risk and may be returned to the Contractor. If so
returned, all costs are the responsibility of the Contractor. Upon discovery of a non-conforming
material or services, the Town may elect to do any or all of the following by written notice to the
Contractor:
a. Waive the non-conformance.
b. Stop the work immediately.
c. Bring material or service into compliance and withhold the cost of
same from any payments due to the Contractor.
3.19 No Replacement of Defective Tender. Every tender of materials shall
fully comply with all provisions of the Contract. If a tender is made which does not fully
conform, this shall constitute a breach of the Contract as a whole.
3.20 Shipment Under Reservation Prohibited. Contractor is not authorized to
ship materials under reservation and no tender of a bill of lading will operate as a tender of the
materials.
3.21 Liens. All materials, service or construction shall be free of all liens and,
if the Town requests, a formal release of all liens shall be delivered to the Town.
3.22 Licenses. Contractor shall maintain in current status all Federal, State and
Local licenses and permits required for the operation of the business conducted by the Contractor
as applicable to this Contract.
3.23 Patents And Copyrights. All services, information, computer program
elements, reports and other deliverables, which may be patented or copyrighted and created
under this Contract are the property of the Town and shall not be used or released by the
Contractor or any other person except with the prior written permission of the Town.
3.24 Preparation of Specifications by Persons Other Than Town Personnel. All
specifications shall seek to promote overall economy for the purposes intended and encourage
competition and not be unduly restrictive in satisfying the Town’s needs. No person preparing
specifications shall receive any direct or indirect benefit from the utilization of specifications,
other than fees paid for the preparation of specifications.
3.25 Public Record. All Contractor Offers shall become the property of the
Town and shall become a matter of public record available for review, subsequent to the award
notification, in accordance with the Town’s Procurement Code.
3.26 Advertising. Contractor shall not advertise or publish information
concerning this Contract without prior, written consent of the Town.
669417.1
3.27 Notices and Requests. Any notice or other communication required or
permitted to be given under this Contract shall be in writing and shall be deemed to have been
duly given if (i) delivered to the party at the address set forth below, (ii) deposited in the U.S.
Mail, registered or certified, return receipt requested, to the address set forth below, (iii) given to
a recognized and reputable overnight delivery service, to the address set forth below or (iv)
delivered by facsimile transmission to the number set forth below:
If to the Town: Town of Fountain Hills
16705 East Avenue of the Fountains
Fountain Hills, Arizona 85268
Facsimile: 480-837-3999
Attn: Mark C. Mayer
With copy to: GUST ROSENFELD, P.L.C.
201 E. Washington Street, Ste 800
Phoenix, Arizona 85004-2322
Facsimile: 602-254-4878
Attn: Andrew J. McGuire, Esq.
If to Contractor: Concast Corporation
1270 East Broadway Road, Ste 111
Tempe, Arizona 85282
Facsimile:
Attn:
With a copy to:
or at such other address, and to the attention of such other person or officer, as any party may
designate in writing by notice duly given pursuant to this Section. Notices shall be deemed
received (i) when delivered to the party, (ii) three business days after being placed in the U.S.
Mail, properly addressed, with sufficient postage, (iii) the following business day after being
given to a recognized overnight delivery service, with the person giving the notice paying all
required charges and instructing the delivery service to deliver on the following business day, or
(iv) when received by facsimile transmission during the normal business hours of the recipient.
If a copy of a notice is also given to a party’s counsel or other recipient, the provisions above
governing the date on which a notice is deemed to have been received by a party shall mean and
refer to the date on which the party, and not its counsel or other recipient to which a copy of the
notice may be sent, is deemed to have received the notice.
4. ALTERNATIVE DISPUTE RESOLUTION.
4.1 Scope. Notwithstanding anything to the contrary provided elsewhere in
the Contract Documents, except for subsection 4.4(g) below, the alternative dispute resolution
669417.1
(“ADR”) process provided for herein shall be the exclusive means for resolution of claims or
disputes arising under, relating to or touching upon the Contract, the interpretation thereof or the
performance or breach by any party thereto, including but not limited to original claims or
disputes asserted as cross claims, counterclaims, third party claims or claims for indemnity or
subrogation, in any threatened or ongoing litigation or arbitration with third parties, if such
disputes involve parties to contracts containing this ADR provision.
4.2 Neutral Evaluator, Arbitrators. The Town will select a Neutral Evaluator
to serve as set forth in this ADR process, subject to the Contractor’s approval, which approval
shall not be unreasonably withheld. In the event that the Town and the Contractor are unable to
agree upon a Neutral Evaluator, the neutral evaluation process shall be eliminated and the parties
shall proceed with the binding arbitration process set forth in Section 4.4 below. The Town and
Contractor shall each select an arbitrator to serve as set forth in this ADR process. Each
arbitrator selected shall be a member of the State Bar of the State of Arizona and shall have
experience in the field of construction law. None of the arbitrators nor any of the arbitrator’s
firms shall have presently, or in the past, represented any party to the arbitration.
4.3 Neutral Evaluation Process. If the parties have been unable to resolve the
disputes after discussions and partnering, but the parties have agreed to a Neutral Evaluator, the
following neutral evaluation process shall be used to resolve any such dispute.
a. Notification of Dispute. The Town through its Contract
Administrator shall notify the Neutral Evaluator in writing of the existence of a dispute within
ten days of the Town or the Contractor declaring a need to commence the neutral evaluation
process.
b. Non-Binding Informal Hearing. The Neutral Evaluator shall
schedule a non-binding informal hearing of the matter to be held within seven calendar days
from receipt of notification of the existence of a dispute. The Neutral Evaluator may conduct the
hearing in such manner as he deems appropriate and shall notify each party of the hearing and of
its opportunity to present evidence it believes will resolve the dispute. Each party to the dispute
shall be notified by the Neutral Evaluator that the party shall submit a written outline of the
issues and evidence intended to be introduced at the hearing and the proposed resolution of the
dispute to the Neutral Evaluator before the hearing commences. Arbitrators shall not participate
in such informal hearing or proceedings process. The Neutral Evaluator is not bound by the rules
of evidence when admitting evidence in the hearing and may limit the length of the hearing, the
number of witnesses or any evidence introduced to the extent deemed relevant and efficient.
c. Non-Binding Decision. The Neutral Evaluator shall render a non-
binding written decision as soon as possible, but not later than five calendar days after the
hearing.
4.4 Binding Arbitration Procedure. The following binding arbitration
procedure, except as provided in subsection 4.4(g) below, shall serve as the exclusive method to
resolve a dispute if (i) the parties cannot agree to a Neutral Evaluator as set forth in Section 4.2
above or (ii) any party chooses not to accept the decision of the Neutral Evaluator. The party
requesting binding arbitration shall notify the Neutral Evaluator of a request for arbitration in
669417.1
writing within three Working Days of receipt of the Neutral Evaluator’s decision. If the
Contractor requests arbitration or if Contractor rejects the Town’s selection of a Neutral
Evaluator, it shall post a cash bond with the Neutral Evaluator in an amount agreed upon by the
parties or, in the event of no agreement, the Neutral Evaluator shall establish the amount of the
cash bond to defray the cost of the arbitration as set forth in subsection 4.4(m) and the proceeds
from the bond shall be allocated in accordance with subsection 4.4(m) by the Arbitration Panel.
a. Arbitration Panel. The Arbitration Panel shall consist of three
arbitrators: the Town’s appointed arbitrator, the Contractor’s appointed arbitrator and a third
arbitrator (or “Neutral Arbitrator”) who shall be selected by the parties’ arbitrators as set forth in
subsection 4.4(b) If more than one consultant or contractor is involved in a dispute, the
consultants and/or contractors shall agree on an appointee to serve as arbitrator. The Neutral
Evaluator shall not participate in the proceedings.
b. Selection of Neutral Arbitrator. The parties’ arbitrators shall
choose the Neutral Arbitrator within five business days of receipt of notification of a dispute
from the Neutral Evaluator. The Neutral Arbitrator shall have the same qualifications as those of
the arbitrators set forth in Section 4.2. In the event that the selected arbitrators cannot agree on
the Neutral Arbitrator as set forth above, the Neutral Arbitrator shall be the Default Neutral
Arbitrator, a person or entity jointly selected by the Town and the Contractor. If the Town and
the Contractor cannot agree on a Default Neutral Arbitrator, the Town and the Contractor shall
each submit two names to an appropriate judge who shall select one person.
c. Expedited Hearing. The parties have structured this procedure
with the goal of providing for the prompt, efficient and final resolution of all disputes falling
within the purview of this ADR process. To that end, any party can petition the Neutral
Evaluator to set an expedited hearing. If the Neutral Evaluator determines that the circumstances
justify it, the Neutral Evaluator shall contact the selected Arbitration Panel and arrange for
scheduling of the arbitration at the earliest possible date. In any event, the hearing of any dispute
not expedited will commence as soon as practical but in no event later than 20 calendar days
after notification of request for arbitration having been submitted. This deadline can be extended
only with the consent of all the parties to the dispute, or by decision of the Arbitration Panel
upon a showing of emergency circumstances.
d. Procedure. The Arbitration Panel will select a Chairman and will
conduct the hearing in such a manner that will resolve disputes in a prompt, cost efficient manner
giving regard to the rights of all parties. Each party shall supply to the Arbitration Panel a
written pre-hearing statement which shall contain a brief statement of the nature of the claim or
defense, a list of witnesses and exhibits, a brief description of the subject matter of the testimony
of each witness who will be called to testify, and an estimate as to the length of time that will be
required for the arbitration hearing. The Arbitration Panel shall review and consider the Neutral
Evaluator decision, if any. The Chairman shall determine the nature and scope of discovery, if
any, and the manner of presentation of relevant evidence consistent with deadlines provided
herein and the parties’ objective that disputes be resolved in a prompt and efficient manner. No
discovery may be had of any materials or information for which a privilege is recognized by
Arizona law. The Chairman upon proper application shall issue such orders as may be necessary
and permissible under law to protect confidential, proprietary or sensitive materials or
669417.1
information from public disclosure or other misuse. Any party may make application to the
Maricopa County Superior Court to have a protective order entered as may be appropriate to
confirm such orders of the Chairman.
e. Hearing Days. In order to effectuate parties’ goals, the hearing
once commenced, will proceed from working day to working day until concluded, absent a
showing of emergency circumstances.
f. Award. The Arbitration Panel shall, within ten calendar days from
the conclusion of any hearing, by majority vote issue its award. The award shall include an
allocation of fees and costs pursuant to subsection 13.4(M) herein. The award is to be rendered
in accordance with this Contract and the laws of the State of Arizona.
g. Scope of Award. The Arbitration Panel shall be without authority
to award punitive damages, and any such punitive damage award shall be void. The Arbitration
Panel shall be without any authority to issue an award against any individual party in excess of
20% of the original Contract amount, but in no event shall any award exceed $2,000,000,
exclusive of interest, arbitration fees, costs and attorneys’ fees. If an award is made against any
individual party in excess of $100,000, exclusive of interest, arbitration fees, costs and attorneys’
fees, it must be supported by written findings of fact, conclusions of law and a statement as to
how damages were calculated. Any claim in excess of 20% of the original Contract amount or in
excess $2,000,000 shall be subject to the jurisdiction of the Superior Court of Arizona, Maricopa
County. Any party can contest the validity of the amount claimed if an action is filed in the
Superior Court.
h. Jurisdiction. The Arbitration Panel shall not be bound for
jurisdictional purposes by the amount asserted in any party’s claim, but shall conduct a
preliminary hearing into the question of jurisdiction upon application of any party at the earliest
convenient time, but not later than the commencement of the arbitration hearing.
i. Entry of Judgment. Any party can make application to the
Maricopa County Superior Court for confirmation of an award, and for entry of judgment on it.
j. Severance and Joinder. To reduce the possibility of inconsistent
adjudications: (i) the Neutral Evaluator or the Arbitration Panel may, at the request of any party,
join and/or sever parties, and/or claims arising under other contracts containing this ADR
provision, and (ii) the Neutral Evaluator, on his own authority, or the Arbitration Panel may, on
its own authority, join or sever parties and/or claims subject to this ADR process as they deem
necessary for a just resolution of the dispute, consistent with the parties’ goal of the prompt and
efficient resolution of disputes, provided, however, that the Contractor, Architect/Engineer and
Project professionals shall not be joined as a party to any claim made by a Contractor. Nothing
herein shall create the right by any party to assert claims against another party not germane to the
Contractor or not recognized under the substantive law applicable to the dispute. Neither the
Neutral Evaluator nor the Arbitration Panel are authorized to join to the proceeding parties not in
privity with the Town. Contractor can not be joined to any pending arbitration proceeding,
without Contractor’s express written consent, unless Contractor is given the opportunity to
participate in the selection of the non-Town appointed arbitrator.
669417.1
k. Appeal. Any party may appeal (i) errors of law by the Arbitration
Panel if, but only if, the errors arise in an award in excess of $100,000, (ii) the exercise by the
Chairman or Arbitration Panel of any powers contrary to or inconsistent with the Contractor or
(iii) on the basis of any of the grounds provided in ARIZ. REV. STAT. § 12-1512, as amended.
Appeals shall be to the Maricopa County Superior Court within 15 calendar days of entry of the
award. The standard of review in such cases shall be that applicable to the consideration of a
motion for judgment notwithstanding the verdict, and the Maricopa County Superior Court shall
have the authority to confirm, vacate, modify or remand an award appealed under this section,
but not to conduct a trial, entertain the introduction of new evidence or conduct a hearing de
novo.
l. Uniform Arbitration Act. Except as otherwise provided herein,
binding arbitration pursued under this provision shall be governed by the Uniform Arbitration
Act as codified in Arizona in ARIZ. REV. STAT. § 12-1501, et seq.
m. Fees and Costs. Each party shall bear its own fees and costs in
connection with any informal hearing before the Neutral Evaluator. All fees and costs associated
with any arbitration before the Arbitration Panel, including without limitation the Arbitration
Panelists’ fee, and the prevailing party’s reasonable attorneys’ fees, expert witness fees and
costs, will be paid by the non-prevailing party, except as provided for herein. In no event shall
any Arbitrator’s hourly fees be awarded in an amount in excess of $200 per hour and (i) costs
shall not include any travel expenses in excess of mileage at the rate paid by the Town, not to
exceed a one way trip of 150 miles, and (ii) all travel expenses, including meals, shall be
reimbursed pursuant to the travel policy of the Town in effect at the time of the hearing. The
determination of prevailing and non-prevailing parties, and the appropriate allocation of fees and
costs, will be included in the award by the Arbitration Panel. Fees for the Neutral Evaluator
shall be divided evenly between the Town and the Contractor.
n. Confidentiality. Any proceeding initiated under ADR shall be
deemed confidential to the maximum extent allowed by Arizona law and no party shall, except
for disclosures to a party’s attorneys or accountants, make any disclosure related to the disputed
matter or to the outcome of any proceeding except to the extent required by law, or to seek
interim equitable relief, or to enforce an agreement reached by the parties or an award made
hereunder.
o. Equitable Litigation. Notwithstanding any other provision of ADR
to the contrary, any party can petition the Maricopa County Superior Court for interim equitable
relief as necessary to preserve the status quo and prevent immediate and irreparable harm to a
party or to the Program pending resolution of a dispute pursuant to ADR provided herein. No
court may order any permanent injunctive relief except as may be necessary to enforce an order
entered by the Arbitration Panel. The fees and costs incurred in connection with any such
equitable proceeding shall be determined and assessed in ADR.
p. Change Order. Any award in favor of the Contractor against the
Town or in favor of the Town against the Contractor shall be reduced to a Change Order and
executed by the parties in accordance with the award and the provisions of this Contract.
669417.1
EXHIBIT A
TO
CONTRACT
BETWEEN
THE TOWN OF FOUNTAIN HILLS
AND
CONCAST CORPORATION
[Notice to Proceed]
See following page.
669417.1
NOTICE TO PROCEED
TO: DATE:
PROJECT NAME/DESCRIPTION:
In accordance with the Contract dated , 2006, you are hereby
notified to commence work on , 2006 and you are to complete the
WORK within consecutive calendar days thereafter. The date of completion of all
WORK is therefore , 2006. Official time extensions thereto shall be considered
and authorized in strict conformance with General Condition or MAG Standard Specifications.
TOWN OF FOUNTAIN HILLS
BY:
ACCEPTANCE OF NOTICE
Receipt of the above NOTICE TO PROCEED
is hereby acknowledged.
BY:
TITLE:
Acknowledged before me this day of , 2006.
NOTARY PUBLIC My Commission Expires
669417.1
EXHIBIT B
TO
CONTRACT
BETWEEN
THE TOWN OF FOUNTAIN HILLS
AND
CONCAST CORPORATION
[Contractor's Notice of Final Acceptance]
See following page.
669417.1
CONTRACTOR’S NOTICE OF FINAL ACCEPTANCE
PROJECT NO. PR 2006-02
PROJECT NAME Desert Vista Skate Park
TO: DATE:
Construction on the above project was completed on
and on a final inspection was made of the subject Work by this office. The work
substantially conforms to the approved plans and specifications. We, therefore, accept those
portions within the public right-of-way into our system for maintenance.
Approved By:
Mark. C. Mayer, Contract Administrator
Recommended By:
Randy Harrel, Town Engineer
cc: Honorable Mayor and Town Council
Town Manager
Town Clerk
669417.1
EXHIBIT C
TO
CONTRACT
BETWEEN
THE TOWN OF FOUNTAIN HILLS
AND
CONCAST CORPORATION
[Bidder’s Submission]
See following pages.
669417.1
EXHIBIT D
TO
CONTRACT
BETWEEN
THE TOWN OF FOUNTAIN HILLS
AND
CONCAST CORPORATION
[Special Terms and Conditions]
See following pages.
669417.1
SPECIAL TERMS AND CONDITIONS
MAG SPECIFICATIONS MODIFIED
SECTION 105.10 – FIELD TESTING
The Town will retain a testing laboratory to check the quality and application rate of the
emulsion seal.
SECTION 107.12 – FURNISHING RIGHT OF WAY
The Contractor, at his own expense, is responsible for the acquisition of any necessary temporary
easements for construction purposes, storage and maintenance purposes, which are required in
addition to existing easements and/or rights of way.
SECTION 108.1.1 - PRE-CONSTRUCTION CONFERENCE
The Contract Administrator will schedule a Pre-Construction Conference to be held at Fountain
Hills Town Hall after completion of the Contract Documents and prior to the commencement of
work.
The purpose of the Pre-Construction Conference is to establish a working relationship between
the Contractor and the Contract Administrator. The agenda will include critical elements of the
work schedule, submittal of schedule, product data submittals, cost breakdown of major lump
sum items, payment application and processing, coordination with the involved utility firms,
emergency telephone numbers for all representatives involved in the course of construction and
establishment of the Notice to Proceed date. Minimum attendance by the Contractor shall be a
responsible official who is authorized to execute and sign documents.
SECTION 108.5.1 - WORKING HOURS
Unless otherwise authorized by the Contract Administrator, in writing, working hours will be
7:00 AM to 5:00PM during winter hours (November, December, January and February); 6:00
AM to 6:30 PM during spring hours (March, April and May); and 5:30 AM to 6:30 PM during
summer hours (June, July, August, September and October), Monday through Friday, with a
half-hour lunch period unless otherwise authorized by the Contract Administrator.
SECTION 110 - MOBILIZATION
The work under this section shall consist of preparatory work and operations, including but not
limited to, the movement of personnel, equipment, supplies and incidentals to the project site; the
establishment of all offices, buildings and other facilities necessary for work on the project, and
for all other work and operations that must be performed prior to beginning work on the various
items on the project sites.
669417.1
The Contractor shall obtain approval of the Contract Administrator when using Town or private
property to park and service equipment and store material for use on this project.
a. The yard shall be fenced and adequately dust-proofed in a manner such as to
preclude tracking of mud onto paved Town streets.
b. Work in the yard shall be scheduled so as to minimize noise at existing residences
and businesses.
c. Equipment, materials, etc., shall be located so as to minimize impact on adjacent
properties. A sound barrier may be required if deemed necessary by the Contract Administrator.
d. The Contractor shall clean up property promptly upon completion of use.
e. Contractor’s request for approval shall specify in detail how he or she proposes to
comply with (a) through (d) above.
No separate payment will be made for mobilization.
669417.1
EXHIBIT E
TO
CONTRACT
BETWEEN
THE TOWN OF FOUNTAIN HILLS
AND
CONCAST CORPORATION
[Technical Specifications]
See following pages.
669417.1
EXHIBIT F
TO
CONTRACT
BETWEEN
THE TOWN OF FOUNTAIN HILLS
AND
CONCAST CORPORATION
[List of Construction Drawings]
See following page.
669417.1
LIST OF CONSTRUCTION DRAWINGS
DATED: 05/03/06
SP-0.0 SKATE PARK COVER SHEET
SP-0.1 SKATE PARK TYPICAL PROFILES/NOTES
SP-0.2 SKATE PARK SITE PLAN
SP-0.3 SKATE PARK AXON
SP-1.1 SKATE PARK METAL MATERIALS PLAN
SP-1.2 SKATE PARK CONCRETE MATERIAL PLAN
SP-1.3 SKATE PARK VERTICAL REFERENCE PLAN
SP-1.4 SKATE PARK JOINTING PLAN
SP-1.5 SKATE PARK PHASE #1 LAYOUT PLAN AND DATA
SP-1.6 SKATE PARK FUTURE LAYOUT PLAN AND DATA
SP-1.7 SKATE PARK PHASE #1 GRADING PLAN
SP-1.8 SKATE PARK FUTURE GRADING PLAN
SP-2.1 SKATE PARK SECTIONS/PROFILES-SECTIONS-1 THRU 9
SP-2.2 SKATE PARK SECTIONS/PROFILES-SECTIONS 10 THRU 16
SP-2.3 SKATE PARK SECTIONS/PROFILES-SECTIONS 17 THRU 26
SP-2.4 SKATE PARK ADD ALT #1 FENCE PROFILES-PANELS “A” THRU “E”
SP-2.5 SKATE PARK ADD ALT #1 FENCE PROFILES-PANELS “F THRU “H”
SP-2.6 SKATE PARK FUTURE FENCE PROFILES-PANELS “A” THRU “I”
SP-3.1 SKATE PARK DETAILS – 1 THRU 9
SP-3.2 SKATE PARK DETAILS – 1 THRU 9
SP-3.3 SKATE PARK DETAILS – 1 THRU 10
SP-3.4 SKATE PARK DETAILS – 1 THRU 5
SP-3.5 SKATE PARK DETAILS – 1 THRU 3
SP-3.6 SKATE PARK DETAILS – 1 THRU 10
NO DATES ON THE FOLLOWING:
SE-1 OF 2 ELECTRICAL DETAILS
SE –2 OF 2 ELECTRICAL SITE PLAN
UDS 1 OF 1 UNDERGROUND DRAINAGE SYSTEM
669417.1
EXHIBIT G
TO
CONTRACT
BETWEEN
THE TOWN OF FOUNTAIN HILLS
AND
CONCAST CORPORATION
[Work Schedule]
See following page.
669417.1
WORK SCHEDULE
This Calendar of Events is an integral part of the Bidding Requirements and Contract
Documents. All times refer to Mountain Standard Time.
Item Date and Time
Advertisement for Bids
Drawings and specifications available to pick up July 12, 2006
Pre-bid Conference, Town Hall July 18, 2006 at 8:30 a.m. MST
Last day to submit approved equals July 25, 2006
(submit to Site Design)
Bid Opening August 7, 2006 at 1:00 p.m. MST
Award Contract August 17, 2006
Schedule of Values Due August 18, 2006
Notice of Award August 18, 2006
Contract Executed by August 18, 2006
Pre-Construction Meeting August 22, 2006
Notice to Proceed August 22, 2006
Begin Construction August 28, 2006
Project Substantially Completed December 4, 2006
Project Completed December 18, 2006
All Project Closeout Materials Due December 19, 2006
(submit to Site Design)
Final Project billing submitted to Susan Gill, Fountain Hills Parks & Recreation, no later than
December 19, 2006.
669417.1
EXHIBIT H
TO
CONTRACT
BETWEEN
THE TOWN OF FOUNTAIN HILLS
AND
CONCAST CORPORATION
[Contractor’s Notice of Final Pay Estimate]
See following page.
669417.1
CONTRACTOR'S NOTICE OF FINAL PAY ESTIMATE
PROJECT NAME Desert Vista Skate Park Date
To the Town of Fountain Hills
The final pay estimate of $ , which represents total and complete payment
under the terms of the contract, fully and completely reflects the actual quantities of work
performed. Said final quantities were mutually measured and agreed upon by authorized
representatives of the undersigned and the Town of Fountain Hills.
Signed and dated this day of , 2006.
BY:
Title:
For:
STATE OF ARIZONA )
) ss
COUNTY OF MARICOPA )
The foregoing instrument was acknowledged before me this day of
, 2006.
Notary Public
My Commission Expires
669417.1
EXHIBIT I
TO
CONTRACT
BETWEEN
THE TOWN OF FOUNTAIN HILLS
AND
CONCAST CORPORATION
[Performance Bond]
See following page.
669417.1
PERFORMANCE BOND
KNOW ALL PERSONS BY THESE PRESENTS:
THAT,
(hereinafter called Principal), as Principal, and
, a corporation organized and existing under the laws
of the State of , with its principal office in the City of
(hereinafter called the Surety), as Surety, are held and firmly bound
unto the Town of Fountain Hills (hereinafter called the Obligee) in the amount of
(Dollars) ($ ), for the payment whereof, the said
Principal and Surety bind themselves, and their heirs, administrators, executors, successors and
assigns, jointly and severally, firmly by these presents.
WHEREAS, the Principal has entered into a certain written Contract with the Obligee, dated the
day of 20 , for the material, service or construction
described as is hereby referred to and made a part
hereof as fully and to the same extent as if copied at length herein.
NOW, THEREFORE, THE CONDITION OF THIS OBLIGATION IS SUCH, that if the said
Principal shall faithfully perform and fulfill all the undertakings, covenants, terms, conditions, and
agreements of said Contract during the original term of said Contract and any extension thereof, with
or without notice to the Surety and during the life of any guaranty required under the Contract, and
shall also perform and fulfill all the undertakings, covenants, terms, conditions, and agreements of any
and all duly authorized modifications of said Contract that may hereafter be made, notice of which
modifications to the surety being hereby waived; then the above obligations shall be void. Otherwise
it remains in full force and effect.
PROVIDED, however, that this bond is executed pursuant to the provisions of Title 34, Chapter 2,
Article 2, Arizona Revised Statutes, and all liabilities on this bond shall be determined in accordance
with the provisions of Title 34, Chapter 2, Article 2, Arizona Revised Statutes, to the extent as if it
were copied at length in this Contract.
The prevailing party in a suit on this bond shall recover as part of his judgment such reasonable
attorneys’ fees as may be fixed by a judge of the Court.
Witness our hands this day of 20 .
_______________________________________
Principal Seal
BY:___________________________________
_______________________________________
Surety Seal
BY:___________________________________
_______________________________________
Agency of Record
COA FORM 02-03
669417.1
EXHIBIT J
TO
CONTRACT
BETWEEN
THE TOWN OF FOUNTAIN HILLS
AND
CONCAST CORPORATION
[Payment Bond]
See following page.
669417.1
PAYMENT BOND
KNOW ALL PERSONS BY THESE PRESENTS:
THAT, (hereinafter called Principal), as
Principal, and _ , a corporation organized and existing
under the laws of the State of , with its principal office in the City of
(hereinafter called the Surety), as Surety, are held and firmly bound
unto the Town of Fountain Hills (hereinafter called the Obligee) in the amount of
(Dollars) ($ ), for the payment whereof, the said
Principal and Surety bind themselves, and their heirs, administrators, executors, successors and
assigns, jointly and severally, firmly by these presents.
WHEREAS, the Principal has entered into a certain written Contract with the Obligee, dated the
day of 20 , for the material, service or
construction described as
which Contract is hereby referred to and
made a part hereof as fully and to the same extent as if copied at length herein.
NOW, THEREFORE, THE CONDITION OF THIS OBLIGATION IS SUCH, that if the said
Principal shall promptly pay all monies due to all persons supplying labor or materials to him or his
subcontractors in the prosecution of the work provided for in said Contract, then this obligation shall
be void. Otherwise it remains in full force and effect.
PROVIDED, however, that this bond is executed pursuant to the provisions of Title 34, Chapter 2,
Article 2, Arizona Revised Statutes, and all liabilities on this bond shall be determined in accordance
with the provisions of Title 34, Chapter 2, Article 2, Arizona Revised Statutes, to the extent as if it
were copied at length in this Contract.
The prevailing party in a suit on this bond shall recover as part of his judgment such reasonable
attorneys’ fees as may be fixed by a judge of the Court.
Witness our hands this day of 20 .
_______________________________________
Principal Seal
BY:___________________________________
_______________________________________
Surety Seal
BY:___________________________________
_______________________________________
Agency of Record
COA FORM 02-04
669417.1
to Concast Corporation in the amount of $326,702.
19.) SUMMARY of COUNCIL REQUESTS by Town Manager.
20.) ADJOURNMENT.
DATED this 15th day of August 2006.
Bevelyn J. Bender, Town Clerk
The Town of Fountain Hills endeavors to make all public meetings accessible to persons with disabilities. Please call 837-2003
(voice) or 1-800-367-8939 (TDD) 48 hours prior to the meeting to request a reasonable accommodation to participate in this meeting
or to obtain agenda information in large print format. Supporting documentation and staff reports furnished the Council with this
agenda are available for review in the Clerk’s office.
Z:\Council Packets\2006\R8-17-06\8-17-06 agenda.doc Last printed 8/15/2006 11:31 AM