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CI,Q OF SAN BERNARDlhb - REQUEO' FOR COUNCIL AC'LbN
From: M.J. Perlick,
Oirector of PelB8lV1J-ADMli~~rr
1987 HAY -5 r/4 ': 2i
Long Term Disability Insurance for
Management and Confidential employees
Dept: Personnel
Date: 5-1-87
Synopsis of Previous Council action:
Approved the purchase of an LTD plan, on March 9,1987.
Recommended motion:
Adopt Resolution
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) 'Signature
Supporting data attached:
FUNDING REQUIREMENTS: Amount: $3,540 for FY 86-87
($21,240 12 month year) ($1770/month)
Phone: X516l
Ward: N/A
Contact person: Mary Jane Perl ick
Source: . Dtrc,~",~,," I O...9V+'"
Finance: L) ... c Jt..-<.
Council Netes:
__ __M ~- l-P,7
Agenda Item No.
I.y
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CI1"9 OF SAN BERNARDI~ - REQUEQ FOR COUNCIL ACMN
STAFF REPORT
The Standard Insurance Company has agreed to provide Long Term Disability Insurance
for Management and Confidential employees of the City of San Bernardino at a cost
of $20.85 per person. All provisions contained in the policy have been agreed to
by the San Bernardino City.Management Association. The estimated cost is $1770 per
month or $21,240 Annually.
75-0264 5-1-.37
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RESOLUTION NO.
RESOLUTION OF THE CITY OF SAN BERNARDINO AUTHORIZING THE
EXECUTION OF AN AGREEMENT WITH STANDARD INSURANCE COMPANY
RELATING TO IMPLEMENTATION OF A LONG TERM DISABILITY PROGRAM FOR
MANAGEMENT AND CONFIDENTIAL EMPLOYEES.
BE IT RESOLVED BY THE MAYOR AND COMMON COUNCIL OF THE CITY OF
SAN BERNARDINO AS FOLLOWS:
SECTION 1. The Mayor of the City of San Bernardino is hereby
authorized and directed to execute on behalf of said City an
Agreement with Standard Insurance Company relating to
implementation of a long term disability program for management
and confidential employees, a copy of which is attached hereto,
marked Exhibit "An and incorporated herein by reference as fully
as though set forth at length.
I HEREBY CERTIFY that the foregoing resolution was duly
adopted by the Mayor and Common Council of the City of San
Bernardino at a
meeting thereof, held on
the
day of
, 1987, by the following vote,
to wit:
AYES:
Council Members
NAYS:
ABSENT:
City Clerk
The foregoing resolution is hereby approved this
day
of
, 1987.
Mayor of the City of San Bernardino
Approved as to form:
5-1-37
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STANOAO INSURANCE OPANY
RECEIPT FOR INITIAL DEPOSIT
J
Received from
of $
Date
, an initial deposit
in connection with the Application For Group Insurance bearing the same date as this Conditional Receipt.
, Location
Received By .
This receipt is subject to the terms and conditions on the
reverse side,
(Name)
(Title)
General
Information
10
Can different amounts ot coverage for separate cia.... of employees be shown in the certificate?
~es CJ No
(Important Notices will be prepared when full schedule of benefits is not to be shown.)
How WI!J.-Premluml be paid?
zY'Monthly
~ 13 per year (accommodates 26 pay periods per year)
o Quarterly
o Semi-Annually
D Annually
Requested
Effective Date
11
Premium due dates and renewals will be the first of the month unless otherwise noted.
$1/,/
t
I, /~Y7
,
Initial
Deposit
12
Minimum first month's premium is required.
Applicant Agrees That:
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.
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ESENTATIVE
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LO~T10N /
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5-1-87
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900 Ch Avenue. Portland. OR 97204-1282
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Pie... Type or Print
Full Legal Name (Exactly as it is 10 be shown in the policy)
Applicant
1
(>1/
"";:: ~-'I C er"/( q,~;.cc
(street)
(city)
(state)
(Zip code)
Nature of Buslne.s (Give detailed description of work involved)
Form of Organization (Explain in detail if more than one applies)
o Corporation 0 Partnership W/6overnment
o Trust 0 Association 0 Labor Union
o Sole Proprietor
D 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:
-
0'
Exclusions
,~
, non-union, etc.).oI"q.../~P"
Special Requests Are any of the following to be covered?
D Psrtners D Elected Officials
o Sole Proprietors 0 .Retirees
o Consultants, other 0 Board of Directors,
than full-time other than full~
employees time employees
D No DYes
o Employees working 20 but less than 30 hours per week
o Foreign Nationals not residing in the United States or Canada
D Other
Waiting Period
For Eligibility
4
Premium
Contributions
5
51.18-11158 (3/86)
D None
D First day of the month following date hired
D First day of the month following days of employment.
o First day after days of eJ11ployment ~ _ L
~Other r;;.. r ",-F ;1IQA~/l -r./IG",/",~~ ~rr ifF N,,,,,,
-
NOTE: For persons who are Members on the proposed effective date, there are two options:
D Only those who have satisfied the waiting period selected above are eligible, Others must serve the balance of the
~ .)lIaiting period,
'Ii!'" All are eligible immediately, regardless of length of service.
Employee Contrlbullons none
D Amount $
If employees contribute.
number of persons eligible
number of persons enrolled
or
%
'A It
EXIIt&,r
c
o
,)
:L
Insurance
Benefits
6
U Lile
U L~e and Accidental Death and Dismemberment (A 0 & D)
o Survivor Income
Classification Ufe
24-Hour AD&D
Insurance reduces
at age
again at 8ge
Insurance terminates at age
o No reduction of insurance because of age 0 No termination of insurance because of age
AD&O Insurance will be subject to the Exclusions shown in the Group Insurance Policy.
o Other Coverages
o Supplemental Life (including spouse coverege where sllowsble)
D Voluntary AD&D
AD&D Insurance will be subject to the ExcluSIDns shown in the Group Insurance Policy.
o Dependents L~e
o Non-Contributory
o Composite (all employees with or without dependents)
o Required (employees with dependents only)
[] Contributory (Elective)
o Short Term Dlssblllty
o Non-Occupational only
[J 24-Hour
Schedule of Benefits
Spouse
Dependent Children
Classification
Weekly Benefit
Non-Occupational Occupational
Reduced by benefits from
=: State Disability Insurance
LJ Workers Compensation
[J 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 TO Benefit
~ ~ % of first $ t :J,/J of monthly insured earnings, Maximum benefit $ .5;,;1 60
o _ % of the first $ of monthly earnings
plus _ % of the next $ of monthly earnings. Maximum benefit $ -
Monthly L TO 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
~ Family social security only when total benefits exceed _ % of earnings
o Other
Minimum Monthly L TO Benefit $50.00_ /, /.
Yo days "I" e;r~ 11';:- .r,c~/"~, P"'I',4j/t!'t!
.-A',(e
EliminaUon Period
Maximum Benefit Period:
o To age 65; graded ADEA 0 5/70 ADEA Benefits 0 Other
Long Term Disability Insurance willbe subject to the Exclusions and Limitations shown in the Group Insurance Policy.
.
c
Does this insurance supplement existing insurance or insurance for which you have applied or intend to apply?
~NO
L; Yes
o
o
,J
Existing
Insurance
7
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 thi}.iRsurance replace existing insurance?
~No
L; Yes
(Name of Insurance Carrier)
Note: If yes, submit a copy of each existing policy and answer the following questions.
1. If life insur"ance is being replaced, does the previous carrier maintain liability for persons who are disabled?
,Pt!.
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.
/f,~ 4- 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 PoHcy:
AMOUNT OF DATE OF LAST DATE
INSURANCE BIRTH WORKED
NAME
REASON NOT
ACTIVELY AT WORK
Special
Requests
9
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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 Ihe 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.