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HomeMy WebLinkAbout1987-155 1 RESOLUTION NO. 87-155 2 RESOLUTION OF THE CITY OF SAN BERNARDINO AUTHORIZING THE EXECUTION OF AN AGREEMENT WITH STANDARD INSURANCE COMPANY 3 RELATING TO IMPLEMENTATION OF A LONG TERM DISABILITY PROGRAM FOR MANAGEMENT AND CONFIDENTIAL EMPLOYEES. 4 BE IT RESOLVED BY THE MAYOR AND COMMON COUNCIL OF THE CITY OF 5 SAN BERNARDINO AS FOLLOWS: 6 SECTION 1. The Mayor of the City of San Bernardino is hereby 7 authorized and directed to execute on behalf of said City an 8 Agreement with Standard Insurance Company relating to 9 implementation of a long term disability program for management 10 and confidential employees, a copy of which is attached hereto, 11 marked Exhibit "A" and incorporated herein by reference as fully 12 as though set forth at length. 13 I HEREBY CERTIFY that the foregoing resolution was duly 14 adopted by the Mayor and Common Council of the City of San 15 16 Bernardino at a meeting thereof, held on reqular 18th day of Mav , 1987, by the following vote, the 17 to wit: 18 AYES: Council Members Estrada. Reilly. Flores 19 Maudslev. Ouiel. Frazier. Strickler 20 NAYS: None 21 22 ABSENT: None 23 ~~~~~ i~fere; apprOVL)hiS l..9'c'"-_ day / / / F',~ //' /. /. /,/ t/;; ,.' / 4/ ~ >~' 'v:-1~,-'I./"'/ ,{// / /1./ c,,/C./r/...}': . Mayor off the City of s~n ~ernardino 24 The foregoing resolution 25 of , 1987. ,June 26 27 28 Approved as to form: ~""""~~'; ". (;d /< ," c'" ~~ City' A torney 5-1-37 STANDARD INSURANCE COMPANY RECEIPT FOR INITIAL DEPOSIT Received from I an initial deposit of $ in connection with the Application For Group Insurance bearing the same date as this Conditional Receipt. Date I Location Received By - This receipt is subject to the terms and conditions on the reverse side. (Name) (Title) General Information 10 Can different amounts of coverage for separate classes of employees be shown in the certificate? ~es 0 No (Important Notices will be prepared when full schedule of benefits is not to be shown.) How w~remiums be paid? IZY"" Monthly 0 Quarterly o 13 per year (accommodates 26 pay periods per year) 0 Semi-Annually o Annually Requested Effective Date 11 Premium due dates and renewals will be the first of the month unless otherwise noted. g" (I t I ~ /YJl7 , Initial Deposit 12 Minimum first month's premium is required. Applicant Agrees That: I If the initial deposit is at least equal to the first month's premium, and if the requested insurance is acceptable to Standard Insurance Company under its current rules and practices, a policy will be issued in the policy language customarily used by Standard and will be effective on the effective date requested. If the initial deposit is not equal to the first month's premium, insurance will not become effective until a policy is delivered to the applicant, and in the interim, Standard's liability is limited.to the return of the initial deposit. No insurance agent or broker has the authority to guarantee the acceptability of the requested insurance. Standard Insurance Company may issue separate policies if more than one coverage is requested in this application. The insurance, if approved. will be subject to Standard Insurance Company's usual underwriting requirements, including, if applicable. Evidence of Insurability and Pre-Existing Condition Limitation. Any insurance for which a Member is required to submit satisfactory Evidence of Insurability will not become effective until Standard sends written notice of approval to the applicant. No premiums shall be collected or paid by the applicant for such insurance until approved. No brochures or other material describing coverage under the group insurance program will be distributed by the applicant to any insured person or prospective insured person without the prior written consent of Standard. 2>1A"€~ 7l)E! d ~PPC '- , -~4f~' LO~TION / (P/I- 5-1-87 Dedicated to Excellence for Policyowners 900 SW Fi~th Avenue, Ponland; OR 97204-1282 Please Type or Print ~";>.(~ ~~~'. - . .\~ ~~ ,:' \.......! ~;.." '.. . }~..: ",,+'. . . :;~~ ..~- ~~'o.;. ~., ;,. ........... Full Legal Name (Exactly as it is to be shown in the policy) Applicant 1 c:."'7Y cr~' ;::;~I g erA q"~40 (street) ( city) (state) (zip code) Nature of Business (Give detailed description of work involved) Form of Organization (Explain in detail if more than one applies) o Corporation 0 Partnership v60vernment o Trust 0 Association 0 Labor Union C Sole Proprietor o Other Affiliates To Be Insured 2 Names And Locations (Affiliates listed below will be covered unless applicant is otherwise notified by Standard) ##. Persons To Be Insured 3 Definition A person must meet an Active Work Requirement to become insured under the group insurance policy. Part-time (working less than 30 hours per week) and temporary personnel will not be covered unless specifically requested. Please define persons to be insured: re/hI'~ Exclusions ~ o No 0 Yes Special Requests Are any of the following to be covered? o Partners 0 Elected Officials o Sole Proprietors 0 Retirees o Consultants, other 0 Board of Directors, than full-time other than full- employees time employees o No 0 Yes o Employees working 20 but less than 30 hours per week o Foreign Nationals not residing in the United States or Canada o Other Waiting Period For Eligibility 4 Premium Contributions 5 51-18-1658 (3/86) o None o First day of the month following date hired o First day of the month following days of employment. o ~irst day after. days of ejTlployment r ~ L ~Other /S/s:;? C1-F nUJA Y'A ~fipl/o~/7 ~ Z3- 4'F Ac;~ NOTE: For persons who are Members on the proposed effective date, there are two options: o Only those who have satisfied the waiting period selected above are eligible. Others must serve the balance of the _ ..,>>'aiting period. 1d' All are eligible immediately, regardless of length of service. Employee Contributions ~one o Amount $ If employees contribute, number of persons eligible number of persons enrolled or 0/0 II/f EXHIt:/r . Insurance Benefits 6 o Life o Life and Accidental Death and Dismemberment (A D & D) o Survivor Income Classification Life 24-Hour AD&D Insurance reduces at age again at age Insurance terminates at age o No reduction of insurance because of age 0 No termination of insurance because of age AD&D Insurance will be subject to the Exclusions shown in the Group Insurance Policy. o Other Coverages o Supplemental Life (including spouse coverage where allowable) o Voluntary AD&D AD&D Insurance will be subject to the Exclusions shown in the Group Insurance Policy. o Dependents Life o Non-Contributory o Composite (all employees with or without dependents) o Required (employees with dependents only) o Contributory (Elective) o Short Term Disability o Non-Occupational only o 24-Hour Schedule of Benefits Spouse Dependent Children Classification Weekly Benefit Non-Occupational Occupational Reduced by benefits from o State Disability Insurance o Workers Compensation o Other Benefits begin on the _ day for accident, and the _ day for sickness. Benefits are payable for Daily Hospital Benefit weeks. DYes o No Short Term Disability Insurance will be subject to the Exclusions and Limitations shown in the Group Insurance Policy. /' ~ Long Term Disability Classification Monthly L TD Benefit ~ ~ % of first $ f! 3' ./'...7 of monthly insured earnings. Maximum benefit $ ..5 d er 0 o _ % of the first $ of monthly earnings plus _ % of the next $ of monthly earnings. Maximum benefit $ _ Monthly L TD benefit will be reduced by all Income From Other Sources unless otherwise specified below: o Income From Other Sources when total exceeds _ % of the first $ and _ % of the remaining earnings o Family social security only when total benefits exceed _ % of earnings o Other Minimum Monthly L TD Benefit $50.00. /~ /.. ~ ...YO days c)" e/l'/ "r s~c~/",q~/ P/h//Cy~ t!- Elimination Period Maximum Benefit Period: o To age 65; graded ADEA 0 5/70 ADEA Benefits 0 Other Long Term Disability Insurance will be subject to the Exclusions and Limitations shown in the Group Insurance Policy. cAc/ce Existing Insurance 7 Does this insurance supplement existing insurance or insurance for which you have applied or intend to apply? ~o eYes Name of Insurance Carrier(s) NOTE:lf yes, submit a copy of each existing policy and/or a description of insurance for which you have applied or intend to apply. Does th~surance replace existing insurance? ~No eYes (Name of Insurance Carrier) Note: If yes, submit a copy of each existing policy and answer the following questions. 1. If life insurance is being replaced, does the previous carrier maintain liability for persons who are disabled? /f/ ~~ DYes 0 No 2. Are you requesting Standard to accept enrollment cards and / or beneficiary designations on forms other than Standard's forms? If yes, enclose a copy of all forms to be approved. /!< ~. 0 Yes 0 No Active Work Requirement 8 Any Group Insurance Policy issued as a result of this application will include an Active Work Requirement. If a person was disabled on the day before the scheduled effective date of his/her insurance, then the effective date of the insurance will be delayed until the first day after the person completes one full day of active work. With prior written approval from Standard's Home Office, the Active Work Requirement may be waived on the effective date of the Group Policy. Before Standard can consider a request to waive the Active Work Requirement, Standard must be provided with a detailed explanation of the reasons supporting the request. In addition, the following information must be provided about each person who will not meet the Active Work Requirement on the effective date of the Group Policy: AMOUNT OF DATE OF LAST DATE INSURANCE BIRTH WORKED REASON NOT ACTIVELY AT WORK NAME /) 4&.w hi S~ckt;k''L ~~:/:, ~ /, ~ /tY'~ //t "'/~ ~~I( .4. /: &7 b~/:'.~f >&) ~utz 62'~ '&//trJ0h ~.~ ,// 5""v~c~.5 /?.;,c Pcc~r&/ /~~-' t!'jC /J/..~"t'i-,eF:/~ ~R//?,r~;t-s:- 7-0 ~Ar'Y Special Requests 9 If the initial deposit is at least equal to the first month's premium, and if the requested insurance is acceptable to Standard Insurance Company under its current rules and practices, a policy will be issued in the policy language customarily used by Standard and will be effective on the effective date requested. If the initial deposit is not equal to the first month's premium, insurance will not become effective until a policy is delivered to the applicant, and in the interim, Standard's liability is limited to the return of the initial deposit. No insurance agent or broker has the authority to guarantee the acceptability of the requested insurance. Standard Insurance Company may issue separate policies if more than one coverage is requested in the application. The insurance, if approved, will be subject to Standard Insurance Company's usual underwriting requirements, including, if applicable, Evidence of Insurability and Pre-Existing Condition Limitation. Any insurance for which a Member is required to submit satisfactory Evidence of Insurability will not become effective until Standard sends written notice of approval to the applicant. No premiums shall be collected or paid by the applicant for such insurance until approved. No brochures or other material describing coverage under the group insurance program will be distributed by the applicant to any insured person or prospective insured person without the prior written consent of Standard. Premium quotations were based on the data submitted to Standard. Final premium rates will be determined on the basis of the actual composition of the group of persons who become insured.