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Your source for professional liability education and networking. ACA & Health Exchanges: The Changing Landscape of Health Care & What it Means for Professional.

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Presentation on theme: "Your source for professional liability education and networking. ACA & Health Exchanges: The Changing Landscape of Health Care & What it Means for Professional."— Presentation transcript:

1 Your source for professional liability education and networking. ACA & Health Exchanges: The Changing Landscape of Health Care & What it Means for Professional Liability Thursday, April 17, 2014 8:00-11:00am Century Square Building 1501 4 th Avenue Third Floor Conference Room Seattle, WA 98101

2 Thank You 2014 Annual Sponsors! Gold Sponsor: Northwest Chapter

3 Thank You 2014 Annual Sponsors! Gold Sponsor: Northwest Chapter

4 Thank You 2014 Annual Sponsors! Gold Sponsor: Northwest Chapter

5 Thank You 2014 Annual Sponsors! Silver Sponsors: Northwest Chapter ADMIRAL INSURANCE Cooper & McCloskey, Inc. Griffin Underwriting Services Regional Excess Underwriters, LLC Skellenger Bender PS Travelers Bond & Financial Products Wells Fargo Insurance Services

6 Professional Liability Underwriting Society Disclaimer: The views and information expressed are the opinions and perspectives of the speakers and do not represent the official position of PLUS, the State of Washington, the Washington Health Benefit Exchange Board or Staff, the Washington State Medical Association or any of the speakers’ employers.

7 Professional Liability Underwriting Society Panelists – Phil Dyer, Senior VP, Healthcare Management Services, Kibble & Prentice, A USI Co. – John Feltz, VP of Select Sales, Cigna Pacific NW Region – Bob Perna, MBA, FACMPE, Senior Director, WA State Medical Association Moderator – Kara Masters, Of Counsel, Masters Law Group & Jerry Moberg & Associates

8 Professional Liability Underwriting Society Introduction Phil Dyer – Emerging Changes in Healthcare Delivery John Feltz – Health Insurance Exchanges & Health Insurance Carriers Bob Perna – Impact on Healthcare Professionals / Professional Liability

9 Professional Liability Underwriting Society Biographical Information Phil Dyer – SVP, Health Care & Management Services, Kibble & Prentice/USI – Phil is the senior specialist for medical professional liability services within Kibble & Prentice’s Integrated Health Management Services. – Phil has 30 years of experience in medical professional liability for physicians, surgeons, group practices and hospitals - having served in various capacities for physician-owned and commercial insurers in this field. He also served as a VP for a major Hospital insurer. – He was a founding Board Member of the National Professional Liability Underwriting Society (PLUS).

10 Professional Liability Underwriting Society Biographical Information John Feltz – Vice President of Select Sales, Cigna – Prior to joining Cigna, John was Senior Vice President of Kibble & Prentice, responsible for Employee Benefits, Property and Casualty, and Professional Liability in the Middle Market division. – John also spent seven years as VP of Sales and Marketing for the region’s leading Third Party Administrator, Healthcare Management Administrators. His role in Senior Management included developing corporate strategy, market strategy, and new business relationships with clients and vendors.

11 Professional Liability Underwriting Society Biographical Information Bob Perna - Senior Director of Health Care Economics and Practice Support for the Washington State Medical Association (WSMA). – Bob oversees the WSMA’s Practice Management Seminars and related educational efforts for physicians, practice managers and administrative staff. He is a frequent contributor to the WSMA’s publications WSMA Reports and Membership Memo, providing information and updates on health policy and reimbursement issues. – Bob has over 40 years’ experience in the health care industry, having held positions in professional relations with a major health insurer and in managerial positions in private medical practices, and in hospital and community health organizations. He also has taught instructional programs on medical practice administration and on procedural and diagnosis coding.

12 Professional Liability Underwriting Society Emerging Changes in Healthcare Delivery Presented by: Phil Dyer

13 Professional Liability Underwriting Society The U.S. Healthcare Industry National Health Expenditures (Billions USD) National Health Expenditure as Share of GDP (Percent) SOURCE: Centers for Medicare & Medicaid Services, Office of the Actuary, National Health Statistics Group In 2012: $2.8 Trillion dollars $8,937 per person By 2020: $13,709 per person (projected) In 2012: $2.8 Trillion dollars $8,937 per person By 2020: $13,709 per person (projected) 13 Currently under enormous financial strain and demographic pressure, healthcare will have to reinvent itself over the next few decades.

14 Professional Liability Underwriting Society ARRA – HITECH The first step to major changes American Recovery and Reinvestment Act (ARRA) including the Health Information Technology for Economic and Clinical Health Act (HITECH) Signed into Law February 17, 2009

15 Professional Liability Underwriting Society Patient Protection and Affordable Care Act (PPACA) Signed into law March 23, 2010

16 Professional Liability Underwriting Society Unprecedented Change: Drivers of Fundamental Disruption in Healthcare Delivery Systems and Payment Methodologies Fundamental Disruption MedicareMedicaid Federal Rules on Health Insurance Health Insurance Exchanges

17 Professional Liability Underwriting Society “No One Ever Washes A Rental Car”

18 Professional Liability Underwriting Society 18 Exchange Value – Specific Functions I. Issuers of QHPs II. Health Care Market III. Public and State Marketing & Outreach Eligibility Determination for tax credits Enrollment Premium Aggregation Easy plan comparison and purchase of health insurance Reporting of cost/quality metrics Awareness of need for health insurance Appeals of eligibility determinations and individual responsibility Information on health insurance carriers Customer Service Enrollment reconciliation with HHS New Membership opportunity – previously uninsured Supporting use of innovative product designs and payment methodologies Expanded access to health insurance coverage Reduced charity care Trustworthy source of health care reform information Broad-based Public Information Other impacts of ACA

19 Professional Liability Underwriting Society The Pace of Change Cultural Transformation of Institutions – 30 years Reimbursement Reform – 10 years Network Changes/ Budget Impacts (Federal/State) – 1 year, recurring annually

20 Professional Liability Underwriting Society The current ‘calm’ in healthcare professional liability An unprecedented period of ‘stability’ in the low frequency of claims and a steady, predictable severity trend, coupled with record levels of financial capacity.

21 Professional Liability Underwriting Society Percentages of Practices Owned by… Source; Medical Group Management Association

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23 Professional Liability Underwriting Society Pressures on Providers Providers  Legal & Business Complexity  Emphasis on Margins, Costs & Resource Allocations  Uninsured Patients  Reimburse- ments and Overall Medical Spending Moving away from patient care as top priority Dramatic increases Demand grows unabated Growing population adding to financial and system stress

24 Professional Liability Underwriting Society Reform ‘Stressors’ Drinking out of a ‘Firehose’ Not enough doctors, expanded mid-levels Undiminished demand for specialists and no one ‘on call’ Resource constraints Absence of tort reform

25 Professional Liability Underwriting Society HC Reform EHRs Compliance (HIPAA-HITECH), RAC/ZPIC, MetaData Value Based Purchasing MCO Liabilities Evidence- Based Medicine Scope of Practice Anti-TrustStark Patients as Consumers? Missed Expectations? ACO: CMS & Private Providers become Payors? Payors become Providers?

26 Professional Liability Underwriting Society ACO AC-SCHMO? CMS Model Private Sector

27 27 Driving the Value Proposition Center of Excellence/ Specialty Institutes Managed Care Shared Risk Specialty Co-management Medical Home Clinical Integration Bundled Payments Accountable Care Integrated Delivery Network/ Health Plan Impact on Value Integration Limited Full Low High Providers are focused on moving from volume to value, which means more integration along the care continuum.

28 Professional Liability Underwriting Society ACOs New or Old? Integrated Delivery System PHO (Physician Hospital Organization) or more? No standardized model in the private sector By 2013, only 30% of physicians will be independent

29 Professional Liability Underwriting Society Exposures associated with ACO activities and services may outweigh traditional insurance coverage Exposures & Mechanisms Insurance Accountability for quality of care Increased involvement in coordination of care Increased control over ACO participants Medical treatment Coordination of care/ case management Medical necessity or other coverage determinations Utilization review (if applicable) Provider selection/ contracting/ termination/payment Claims processing/ payment (if applicable) Billing Employment practices Compliance with state and federal laws, including HIPAA, HITECH and PPACA

30 Professional Liability Underwriting Society P/P/P PatientProviderPayment

31 Professional Liability Underwriting Society ROLE PLAY ? Providers Becoming Payors Payors Becoming Providers

32 Professional Liability Underwriting Society It’s Happening! Some hospital networks also become insurers – By Roni Caryn Rabin – Kaiser Health News, August 25, 2012

33 Professional Liability Underwriting Society “Follow the Money!” Aetna acquires Coventry Health$5.6B Wellpoint buys Amerigroup$5.0B Cigna buys Wellspring$3.8B United buys Monarch Health$5.6B Highmark acquires West Penn Allegheny$470M

34 Professional Liability Underwriting Society Increased Liability Issues New Standards of Care More Causes of Action Direct Liability ACO Vicarious Liabilities More Stringent Informed Consent Integration Challenges

35 Professional Liability Underwriting Society “Corporatization” of Medicine Will increased “institutionalizing” of medicine make patients feel more disconnected from their providers, and more willing to bring action against “nameless, faceless” corporations? Professional Liability Historic Claim Etiology AngerResentment Communi- cation Missed Expectations

36 Professional Liability Underwriting Society 36 Strategic RisksFinancial Risks Patient Safety/Quality Initiatives & Outcomes Ethics Planning Technology Union relations Competition (Private/Public) Healthcare Delivery System evolution/changes Media coverage Product design Debt rating, Liquidity/cash, Asset valuation Federal Regulatory Impacts; (CMS), Health Care Reform State Regulatory Impacts; DSHS, DOH, Health Care Reform Payors Reimbursements/Contract Terms/Provider Panels & Standards Interest rates Economic growth Changing patient demographics Changing Provider demographics Operational RisksHazard Risks Physician Recruiting Professional Staffing and Personnel Retention Discrimination Embezzlement & Employee Dishonesty Workplace violence Service provider failures, such as phone or utility service Supplier business interruption First Party Liabilities (Assets, Cyber, Brand) Third-party General Liabilities (GL, Cyber, Bio-Tech, etc.) Professional Liability Mgmt. Liability (Directors and Officers/EPL) Health and safety (Occupational) Catastrophic Natural hazards, (e.g. flood/ EQ) Catastrophic hazards; Terrorism, war, radioactivity, intentional bio-release, etc. Mass Torts; e.g. medical products, technology, procedures, methodology Healthcare Enterprise Risk Management

37 Professional Liability Underwriting Society Questions?

38 Professional Liability Underwriting Society PPACA & Exchanges PPACA & Exchanges: Impact on the Landscape of WA Insurance Presented by: John Feltz

39 Professional Liability Underwriting Society  Global Perspective of PPACA and Exchanges  Effects of PPACA, particularly Exchanges, on Employers  Carrier Perspective: Opportunities Moving Forward PPACA and “Exchanges”:

40 Professional Liability Underwriting Society Who is eligible to purchase coverage through a Health Insurance Exchange? Anybody can purchase health insurance through an Exchange. The most likely purchasers include: – Unemployed people – Self-employed people – People that work for businesses that don’t offer insurance – People with plans that are unaffordable

41 Professional Liability Underwriting Society Health Insurance Exchanges must be “Qualified Health Plans” (QHPs). Name three attributes of a QHP. 1.They are certified by the Health Insurance Exchange through which they are offered. 2.They provide EHBs. 3.They offer one Silver Plan, one Gold Plan, and a Child-Only Plan. 4.They charge the same premium for a particular plan whether sold on or off the Exchange.

42 Professional Liability Underwriting Society Health Insurance Exchanges will offer standard health plans at four benefit levels. Name those levels and give the associated cost share/actuarial value for each. PlanCost Share/Actuarial Value Platinum90% Gold80% Silver70% Bronze60%

43 Professional Liability Underwriting Society A client offers health insurance coverage to all of its Full- Time Employees, with a contribution strategy in which the employer pays $5,000/year per employee, leaving the employee to pay $3,000/year. Employee salaries range from $25,000 to $140,000. Will some employees be likely to purchase insurance through an Exchange? If so, why? Yes, depending on the total cost of coverage, the employer’s plan may not be ‘affordable’ under PPACA (employee contribution <9.5% of W-2 income.) Employees can purchase subsidized coverage through the Exchanges.

44 Professional Liability Underwriting Society Name three things that ‘large employers’ (more than 50 Full-Time Employees) must do to stay in compliance with PPACA. 1.Make employees eligible for coverage within 90 days of hiring 2.Cover all Full-Time Employees (individuals working > 30 hours/week) 3.Offer coverage to employees dependents (but not spouses) 4.Automatically enroll new employees in employee-only coverage 5.Notify employees of Exchanges and their potential eligibility for subsidies. 6.Provide coverage that provides ‘minimum value’ – coverage at least 60%, and is ‘affordable’ (<9.5% of W-2 income).

45 Professional Liability Underwriting Society What are some differences between a Public Health Insurance Exchange and a Private Health Insurance Exchange? 1.Private Exchanges do not provide any type of public assistance. 2.PPACA Exchange rules do not apply to Private Exchanges. 3.Private Exchanges are privately owned and operated. 4.Private Exchanges have more flexibility in benefits and services.

46 Professional Liability Underwriting Society Why should a ‘large employer’ under PPACA care about Exchanges? If the health care plan it offers isn’t ‘affordable,’ or doesn’t provide a plan with ‘minimum value’ under PPACA rules, employees may choose to purchase subsidized coverage through a State Health Insurance Exchange. The company would then incur penalties.

47 Professional Liability Underwriting Society How much is the penalty for a ‘large employer’ not offering coverage to its employees? The Penalty is the lesser of: $3,000 per Full-Time Employee receiving a tax credit for Exchange coverage, or $2,000 per Full-Time Employee (minus the first 30)

48 Professional Liability Underwriting Society If you have a client that offers a high-value plan that is not ‘affordable’ for all employees under PPACA regulations, how would you recommend that the client change its plan to avoid penalties? Recommend that the client considers adding lower-cost plan options.

49 Professional Liability Underwriting Society Global Perspective of PPACA and Exchanges

50 Professional Liability Underwriting Society EXCHANGES – PUBLIC VERSUS PRIVATE State Health Benefit ExchangesPrivate Exchanges Operating ModelInformation Aggregator to Market Negotiator Private label offering to employers with participating carriers OversightGovernment Agency, quasi-governmental agency or not for profit Privately owned and operated Stated ObjectiveAssist individuals, families and small employers to purchase health insurance Provide assistance to those who qualify for enrollment in state Medicaid programs Offer services to the various individuals and groups in the purchase of healthcare coverage Defined Contribution Subsidy AvailabilityYes, for those individuals and families between 100-400% of FPL No, public subsidies tied to income levels are not available EligibilityIntended for individuals and small employers looking to purchase healthcare coverage Employers choosing to participate and their eligible employees Rate NegotiationFocus is on individual and small employer and rating regulations are very strict in these lines of business Negotiated with private exchange Employer SizeSmall employers as defined by state, either 1-50 or 1-100 until 2016 when all states go to 100 Any size employer ExamplesMassachusetts and WashingtonBloom Health, and Aon Hewitt (1/1/13) Over 100 private exchanges exist today in small group

51 Professional Liability Underwriting Society Employer Purchasing under PPACA LOWHIGH Employer Engagement and Control Public Exchanges Private Multi- Carrier Exchanges Private Carrier Run Exchanges Private Third Party Single and Multi- Carrier Exchanges Private Established Carrier Model

52 Professional Liability Underwriting Society Private Exchange Value Proposition Employer Eliminates or minimizes healthcare procurement process Defined contribution - Allows an ER to commit specific amount of money for benefits with the option to tie increases to something other than trend Transparency of full cost of benefits, shared with EEs Employee Employer sponsored benefits continue, pre tax EE contribution Transparency of the full cost of benefits Increased choice and control

53 Professional Liability Underwriting Society What is an ‘Exchange’ Anyway? From: To:

54 Professional Liability Underwriting Society Effects of PPACA, Particularly Exchanges, on Employees

55 Professional Liability Underwriting Society Employers’ Concerns Two primary issues facing employers today:  The complexities of Health Care Reform  The escalation of costs associated with employee health care Employers’ fundamental business concerns are:  Managing Risk  Increasing Revenue  Mitigating Expenses

56 Professional Liability Underwriting Society The Washington State Marketplace Credibility > Past Community Trusts Data <50 employees 150-250 employees 50-150 employees >250 employees Public Exchange Trusts Credibility > Carrier & 3 rd Party Exchanges 100 Future

57 Professional Liability Underwriting Society Consider the Options Involvement with benefits, health and productivity Involvement with financing Opt Out Defined contribution approach & Private Retail Exchange Stay the course Full throttle on health, wellness and productivity

58 Professional Liability Underwriting Society Intended Consequences  Get uninsured covered  Leverage Federal subsidies  Migrate WSHIP model to standard PPACA model  WA didn’t have some of the issue that the other states have had (recision practices, no high-risk pool, limited mandated benefits)  How are we doing compared to other states?

59 Professional Liability Underwriting Society Unintended Consequences II ncreased regulatory appetite EE xample: What’s happening with the trusts? LL ong term affordability? Possibly, but costs in general are not going down

60 Professional Liability Underwriting Society Carrier Perspective: Opportunities Moving Forward

61 Professional Liability Underwriting Society Employer Engagement and Control LOWHIGH Emerging group models: Private single carrier model Hosted by carrier or 3rd party, single carrier offered to customer Funding - ASO or Insured Delegation of plan oversight varies by model - Pre-packaged menu (e.g. medical, dental, supplemental) - Pre-packaged with employer discretion to offer all or a subset of menu - Products and plans determined by employer (defined contribution play vs ‘exchange’) Products and Plans - Increased employee product and plan choice to meet individual needs Defined contribution by employer Group plan underwritten based on employer’s experience Increasing single-carrier development activity in marketplace

62 Professional Liability Underwriting Society Questions to Consider  Can employers afford to give up more cost control? Do they have to?  Is the role of the broker / consultant changing?  Does a “Defined Contribution” model match with a strong desire to offer strong benefits at a competitive price?  Where have we seen this before?  Any other questions?

63 Professional Liability Underwriting Society Impact on Healthcare Professionals & Professional Liability Presented by: Bob Perna

64 Professional Liability Underwriting Society Exchange and Physician Practices Topics Enrollment levels in Medicaid and Individual QHPs Individual Exchange; SHOP Sources of health care services; Access to care Network Adequacy and “Narrow Networks” Financial Solvency of Physician Practices Grace Period ASO lines of business Health Care Data “Transparency”

65 Professional Liability Underwriting Society Exchange and Physician Practices February Enrollment Report – Released March 20 Qualified Health Plans: 112,225 Medicaid Newly Eligible Adults: 235,079 Previously Eligible but not Enrolled: 122,302 Redeterminations (Previously Covered): 370,469 Subtotal: 727,850 Total: 840,075 In-Process Applications Qualified Health Plan Applicants – Need to Pay: 71,787

66 Professional Liability Underwriting Society Exchange and Physician Practices Expanded Enrollment meets Limited Capacity = Low Access These are not “new Washingtonians.” Uninsured: Didn’t seek care, or sought care in sporadic, episodic manner ( ERs ) Result: ineffective care management. Or sought care through Community Clinics / FQHCs / RHCs. Now, with Medicaid expansion & Individual coverage through the Exchange: Adding a lot more people into the mainstream of the healthcare system. But we have not increased the number of primary care and specialty doctors at the same rate. Could create access problems, especially in already underserved areas, as the newly insured seek care, increasing the demand on the delivery system. Increased risk of professional liability claims?

67 Professional Liability Underwriting Society Exchange and Physician Practices Small Business Health Options Program (SHOP) Only Kaiser participated in the SHOP Exchange in 2014, operating only in Clark and Cowlitz Counties (operations based in Portland). Consider the amount of confusion and disruption that occurred in 2013 & 2014 in dealing with only the Individual Market Exchange. Think how potentially disruptive it would have been if health insurers also had been heavily involved in the SHOP Exchange in 2014. May have “dodged a bullet.” But what about 2015??? Not hearing a lot of interest.

68 Professional Liability Underwriting Society Exchange and Physician Practices Dramatic increase in covered Medicaid lives Where will these Medicaid patients go for care? * Traditional resources: Community Health Clinics. Sufficient capacity? * “Mainstream” physician practices? Unprepared, ill-equipped to address the needs of Medicaid patients. Patients’ medical needs that were not addressed will require more intensive initial assessment and treatment: * Higher initial expenditures of time and resources. * Potential for less favorable care outcomes. * Increased professional liability? Increased percentage of Medicaid patients ( “patient mix” ): * Lower payment rates. Destabilize the financial solvency of practices?

69 Professional Liability Underwriting Society Exchange and Physician Practices Expanded Enrollment meets Limited Capacity = Low Access WA Office of Financial Management study, conducted by the University of Washington: Washington State Primary Care Provider Survey, 2011-2012 We potentially do not have enough primary care providers to adequately care for all new Medicaid enrollees. University of Washington Center for Health Workforce Studies and Rural Health Research Center Sue Skillman, Deputy Director http://depts.washington.edu/uwchws/ http://depts.washington.edu/uwrhrc/

70 Professional Liability Underwriting Society Exchange and Physician Practices Expanded Enrollment meets Limited Capacity = Low Access Wait times As the demand for health care services increases, without an increase in the number of providers and the capacity to offer services, patients could experience longer lead times in obtaining needed appointments, especially in already underserved areas. Delays in obtaining care could: * Result in less favorable health outcomes * Increase professional liability.

71 Professional Liability Underwriting Society Exchange and Physician Practices Network Adequacy vs. “Narrow Network” WA OIC reviews and monitors carriers’ networks to ensure that the carriers have engaged an adequate network to meet the care needs of patients enrolled in that plan. Some carriers are using a “narrow network” strategy, providing a very limited choice of providers, and making lower payments – or no payments – for care rendered “out of network”. Physicians and practice staff need to consider this “out of network” provision when assessing a contract offering from a carrier, and when verifying a patient’s enrollment prior to providing services.

72 Professional Liability Underwriting Society Exchange and Physician Practices Network Adequacy vs. “Narrow Network” Past: * Health Insurers sought to develop the largest possible networks; * Selling point with Purchasers: Greater access; happy subscribers Health Insurers then migrated to “tiered” networks: * Assign providers to different tiers, based on some form of assessment. * Varied payment levels. Current: Moving to “narrow networks”: * Does a “narrow network” satisfy Network Adequacy standards? * Opportunity for Health Insurers to roll back payment amounts? * What options can Physician Practices consider?

73 Professional Liability Underwriting Society Exchange and Physician Practices Grace Period – SB 6016 PASSED ACA sought to provide greater assurance of continuity of coverage, and guard against health insurers’ unfair terminations of insurance coverage when the enrollee falls behind in paying premiums. Insurers typically had allowed a 30 day grace period. ACA raised that grace period to 90 days. Unintended consequences: * Patient could be up to 90 days in arrears in payment premiums; * Provider not notified of this by patient or health insurer. Any “prior authorization” assumes patient will catch-up on payments. * Provider continues to give services, believing coverage is in force. * If patient does not pay premiums, health insurer reverses coverage back to last paid month. Provider must then pursue Patient for unpaid balances, assuming Patient is not eligible for other coverage, such as Medicaid.

74 Professional Liability Underwriting Society Exchange and Physician Practices Grace Period – SB 6016 PASSED Bill established: * Notice to Patient when behind on premiums. * Notice to Provider when Patient is behind on premiums.

75 Professional Liability Underwriting Society Exchange and Physician Practices Other issues: Rise of ASO arrangements Regulatory oversight role of the WA OIC in protecting consumers: diminished? “Transparency” Sharing of health care data is essential to the success of emerging payment models ( e.g.: Accountable Care Organizations ) and in achieving control of health care expenditures, as well as improvements in care quality. Failure to effectively share data: Increased risk of professional liability. Very limited capabilities in Health Information Exchange (HIE). Large Integrated Health Delivery Systems, by default, become “hubs” for data sharing. All Payer Claims Data Base?

76 Professional Liability Underwriting Society Questions?

77 Thank You 2014 Annual Sponsors! Gold Sponsor: Northwest Chapter

78 Thank You 2014 Annual Sponsors! Gold Sponsor: Northwest Chapter

79 Thank You 2014 Annual Sponsors! Gold Sponsor: Northwest Chapter

80 Thank You 2014 Annual Sponsors! Silver Sponsors: Northwest Chapter ADMIRAL INSURANCE Cooper & McCloskey, Inc. Griffin Underwriting Services Regional Excess Underwriters, LLC Skellenger Bender PS Travelers Bond & Financial Products Wells Fargo Insurance Services

81 A Special Thank You to: Northwest Chapter Phil Dyer John Feltz Bob Perna Kara Masters


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