HomeMy WebLinkAboutOrdinance No. 552 CITY OF THE COLONY, TExAs
ORDINANCE NO. ~o~'
AN ORDINANCE OF THE CITY OF THE COLONY, TEXAS,
AUTHORIZING THE CITY MANAGER TO ENTER INTO A CONTRACT
FOR INSURANCE COVERAGE FOR CITY EMPLOYEES; ATTACHING THE
APPROVED FORM OF CONTRACT AS EXHIBIT "A"; AND PROVIDING AN
EFFECTIVE DATE
BE IT ORDAINED BY THE CITY COUNCIL OF THE CITY OF THE
COLONY, TEXAS:
Section 1. That the City Manager of the City of The
Colony, Texas is hereby authorized to execute on behalf of the
City a contract with ~/~/N &ro~ ~/1~,o~ Lr~ /~~
for insurance coverage for city employees. The approved form of
such contract is attached hereto as Exhibit "A", and made a part
hereof for such purposes.
Section 2. This Ordinance shall take effect immediately
from and after its passage by the City Council of the City of The
Colony, Texas.
DULY PASSED AND APPROVED by t~e City Council of the City of
The Colony, Texas, on this the ~4 day of ~~ , 1988.
APPROVED:
Don Amick, Mayor
ATTEST:
~jt~....~.W~'A~Hicks, City Secretary
~ y , ~ty A y
SUPPLEMENT Td MASTER APPLICATION
WASHINGTON NATIONAL INSURANCE COMPANY
State law requires that the Company offer each Policyholder certain coverage(s) which the Policyholder may
either accept or reject. A PoLicyholder who accepts this coverage must complete and sign section I of this
form. A PoLicyholder who rejects it must sign section II.
I. In consideration of the additional premium required, if any, I request that the Company add the optional
coverage{s) listed below to my new or revised group health policy.
[] Home Health Care
[] In Vitro Fertilization
[] Optional Benefit for Mental Disorders -- This optional benefit is in addition to Washington Na-
tional's standard outpatient coverage. It pays the insured percentage of covered charges for:
1. inpatient treatment and outpatient convulsive therapy; and'
2. care in lieu of hospital inpatient care in a psychiatric day treatment facility, a residential treat-
ment facility for children or adolescents, or a crisis stabilization unit.
PLEASE NOTE: For PoLicyholders who reject this option, only Washington National's standard
outpatient coverage will be included in the policy.
This additional coverage shall become effective on:
1. the date the poLicy is effective, if it is a new policy; or
2. the date of the revision which caused this optional coverage to be offered, if the policy is being revised:
Date Signature of Policyholder
II. I do not want the additional optional coverage{s) offered above.
/ / Date
If this coverage is being offered because this is a new Policyholder, this form shall be attached to and made a
part of the Master AppLication, and submitted with the Master Application. If this coverage is being offered
because an existing policy is being revised, this form shall be considered a supplement to the original Master
Application the Policyholder has already submitted.
F15767 (1-88)
TX
MASTER APPLICATIO'I~ FOR GROUP INSURANCE
made to WASHINGTON NATIONAL INSURANCE COMPANY, EVANSTON, ILLINOIS 60201
Full Legal Name of Proposed Pollcyholden Cit.¥ Of t. he Co].ony :':'
Legal Street Address: 5151 Nort. h Colony Boulevard
City: The C01ort.~ State: Texas Zip Code:' 75056
Authorized Repre~entatlve/'Tltle: w-~ 1 't i nm M- T~I 1 - C'i t-_v M~nng~-
Nature of Business or Organization: H~n i n~ _~l ~ ~-._v
Policyholder Contribution: Employee Premium Life 100 ~/0 Health 100 %
Dependent Premium Life 0 % Health 0 %
Waiting Period Is: [] 1st of Month After of Employment
[] 1st of Month After Date of Employment
[] Other:
Waiting Period [] IS F'~ IS NOT applicable on policy effective date.
INDICATE BELOW ALL OF THE COVERAGES FOR WHICH APPLICATION IS MADE
[] Life Insurance [] Basic Medical with I~ Dental Expense
Supplemental Major Medical
[] Accidental Death, Dismemberment [] Comprehensive Major Medical [] Vision Care
[] Dependent Life [] [] Prescription Drug
[] Disability Income [] []
DESCRIPTION OF ELIGIBLE CLASSIFICATIONS AND BENEFIT LEVELS ARE DETAILED ON THE SCHEDULE OF
BENEFITS PAGE CONTAINED IN THE WASHINGTON NATIONAL PROPOSAL DATED A~ousl: 17. 1988.
The proposed effective date requested for this group Insurance Is Se~t. ernh~' 1. 1 c~RR
The sum of $ ]- , 0 0 0.0 0 has been tendered as a deposit to be applied toward premium due.
. I UNDERSTAND THAT THE POLICY(lES) WILL NOT BECOME EFFECTIVE UNLESS AND UNTIL WASHINGTON
NATIONAL INSURANCE COMPANY'S HOME OFFICE APPROVES THIS APPLICATION.
The £ol(~ny this ~1 dayo~,//~, -~_H~~ ~- 19F~l '
Signed at
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