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HomeMy WebLinkAboutOrdinance No. 658 CITY OF THE COLONY, TEXAS ORDINANCE NO. &~-Z AN ORDINANCE OF THE CITY OF THE COLONY, TEXAS, AUTHORIZING THE CITY MANAGER TO ENTER INTO A CONTRACT FOR EMPLOYEES INSURANCE COVERAGE; 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 ~f~/F~ /~. ~.~ ~gO~/~/~O /~,~/4 for employees insurance coverage. 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 the City Council of the City of The Colony, Texas, on this the / 7~'~day of ~ 1990. APPROVED: William W. Manning, Mayo~_.~k ATTEST: Patti A. Hicks, City Secretary [SEAL] APPROVED AS TO FORM: John Boyle, City Attorney ~Ufe of Georgia APPLICATION FOR GROUP INSURANCE TO LIFE INSURANCE COMPANY OF GEORGIA (HEREIN CALLED ]'HE COMPANY) 1. Full Legal Name 2. Employer I,D. No. 3. ERISA Plan No. City of The Colony 75-1570670 214-625-1756 4. Main Address (Street, City, County, State Et Zip) 5. Telephone No. 5151 North Colony Blvd. The Colony, Tx. 75056 6. Nature of Business (Describe Fully) 7. Approx. % of Employees Mun i cipal ity Living Inside City Limits 90 % % 8. Business Entity [] Corporation [] Proprietorship [] Other (Describe( [] Partnership ~ Government Agency 9. Associated Business Organizations whoso Employees are to be eligible: Name Address How Associated No. Employees 141 3 5 10. Total Number of Eligible Employees ! 11. Number With Dependents 12. Class or Classes Not Eligible IPar~ Time (Less Than 30 Hours( and Temporary Are Not Eliglblel List Other Excluded Class No. Excluded 13a. Employees Not Actively At Work: The Applicant hereby notifies the Company of the following employees who are not presently actively at work and who are insured for similar coverage under the plan being replaced. If none, enter "None". Nick Ristagno has coverage thru november & then can take COBRA[ 13b. Do you have any COBRA participants? l~ Yes [] No If "Yes," p~ease allach a copy of their election form. 14. Waiting Period: on the first o-f the f~Ilowln9 mu*tLh Present Employees N~A None Future Employees after date of hire. 15a. Present Insurer 15b. Type of Coverage 1!5c. Date of Termination Washington National Medical & Dental 9-30-90Midnight 16. Benelits Applied For: 17. The [ollowing coverages must be offered in the 3~] Life Insurance, [] Dependents to be insured State of issue: Are They Applied For? [-4zfAccidental Death and Dismemberment Insurance Policyholder [] Weekly Income Benefits Yes No Initial [3fMedica[ Insurance, [2]~ependents to be insured [] [] [] Dental Insurance, [] Dependents to be insured [] [~ CK Cost Containment [-j [] ~] Other [~] ~] 18. Employer will contribute: ] ~ ~ ~ of the Employee Premium NON~ of the Dependent Premium 19. It is requested that the insurance applied for become effective at 12:01 A.M. on O~:l-_c;t;~=~r__]~,__'~ .') ~ ~F~ If the application satisfies the Company's requirements, Life of Georgia witl issue a Group Policy. Any policy issued will become effective on the date requested only if: (1) The Applicant accepts the rating basis and all terms, conditions, amendments, or ddels of the po[icy; and (2( The first full premium is paid. The Colony, Texas Dated at this --].~1. day of C)c'~- ~h~ r ~ 19~0_ Full legal name of applicant City Of the COlOT~y syWilliam M. Hal .... Title _C/J~y M~na_ger Witness ]<~'h~=r~ tie Ma 7-~- ~ ne_~ Personnel Di-r~c,3c-O,i~snt, if not Witness Form 1119 Rev. 7-84 5/87 .................. prem~ium .... 2 ..... Receivedof The City of The Colony adgg/~of $30,106.54 dollars, payment in full Applicant for October 1990 This deposit is made at the time of the submission of an Application for Group Insurance to the Life Insurance Company of Georgia. Any Insurance which becomes effective will be in accordance with the terms, conditions, amendments, or riders of the Policy issued by the Company. The Insurance will begin on the requested effective date, provided that: (1) this application sat!sties th? Company's requirements; (2) the Applicant accepts the rating basis and all terms, conditions, amendments or riders of the policy; and {3) the first full premium has been paid. if the insurance is issued, the deposit will be retained by the Company and credited to the premium for the Insurance; if the Insurance is not issued, the deposit will be returned upon surrender of this receipt. Date By LIFE INSURANCE COMPANY OF GEORGIA P. O. Box 105006 · Atlanta, Georgia 30348-5006 .K INK FR~LiMii,~ARY APPLICATION FOR GROUP INSURANCE ANiERITAS LIFE INSURANCE CORP.--LINCOLN, NEBRASKA ~ (See Reverse Side For Additional Information) 1. Applicant's Legal Name: ~. _ ~ ~lt~ Of The Colon_y______ 9.~f the .month following/coinciding 2. Address: 5151 North Colony Blvd. The Colony, Tx. 75056 9. Waitlng Period: 0 - months, for those ¢'mployed on or before the policy effec- (If P.O. Box, please provide street address) 0 tive date. months, for those em~,loyed after the policy effective date. Telephone Number: 21 4- 6 2 5-17 5 6 (ORi If a waiting period of calendar or working days is desired, please so 3. Nature of business or industry: indicate: __ Municipality [] calendar [] working number of days .. 4. Are any classes or locations excluded? ~ Is first of month effective date. end of month termination date ._.____~{If yes, please use reverse side for explanation.) desired? 5. Are any subsidiary and/or affiliated companies to be insured?. 10. Premiums to be paid in advance; (If yes, please use reverse side to list name and Iocation.} [~ monthly [] quarterly [] semi-annual [] annual 6, Number of full-time eligible: Employees _. Dependents Of this number how many are If policy effective date is other than first of the month, is a first of the COBRA continuees: month premium due date desired? N Employees. Dependents None . . 11. The following coverages are applied for: How many hours per week equals full time employment? 3 0 & UD Employee Benefits Dependent Benefits 7. Employee Participation: O Life Ins. [] Life Ins. a) ~] compulsory/non-contributory, (means proposed policyholder [] Supplemental {where al)owed) Life Ins. contributes 100% of premium, all employees must be in- [] AD&D sured, except those noted in item #4.) ~Dental [] Short Term Disability [;~Orthodontia b) [ i voluntary/contributory, ("means the proposed policyholder is ~] include Death BeneJit ~J Vision required to contribute to the employee premium and must ~ Dental [] contribute at least 25% of the total employee end dependent ~ Orthodontia premium.) [] [] Vision [] Wbat % of employee premium does the proposed policy- []' Rease use reverse side to holder contribute? __ % []-- list plan design and proposed c) LJ compulsory/non-contributory, except for employees covered [] rates. elsewhere for dental insurance, (means if proposed policy- 12, Insurance requested on this application will replace the coverage(s) holder contributes 100% of premium, all employees must checked: be insured, except those noted Jn item #4 and those covered elsewhere [or dental insurance.) [] Life ~ Supplemental Life [] AD&D [] Short-Term Disability 8. Dependent Participation; ~ Dental l~Orthodontia [] Vision []. []_ Name of carrier.~..~,~-Li~-~-,-~_~ a) I; Compulsory/non-contributory, (means proposed policyholder effective date ~--1-~8'8'''--- Nati~s_ contributes 100% ct premium, all dependents must be in- being replaced 9 - 3 0 - 9 0 and temninatlon data of insurance sured except those noted in item #4.) Do you ha,~(~ther group insurance in force with Ama tas L e thsu ance b) !Z voluntary/contributory, (see b" under item #7) Corp.? If yes, please identify. What % of dependent premium does the proposed policy- holder contribute? O-- % c) [ 1 compulsory/non,contributory, except for dependents covered 13. This insurance shall be.e~fective 12:01 A.M. Standard Time on elsewhere [or dental insurance, (means if proposed policy- gc'coDer j., .L ~ ~0 holder contributes 100% ct premium, all dependents must be at the applicant's address provided the application is accepted at the insured, except those covered elsewhere for dentaJ insurance.__~_) Home Office of the Company. THE APPLICANT DECLARES that he/she has read the statements and the answers to the above questions and that they are complete and true. The appli- cant agrees that this application is made to induce the Company to issue the insurance applied for; such insurance to be in the amounts agreed upon by the Company and lbo Applicam. Group Insurance at the Company's rates and under the terms of the policy(les) applied for shall take effect as of the date shown in section 13 if this )ppllcation is accepted at the Home Ofhce of the Company. But in case this application is not accepted, any premium advanced by the Applicant shall be efunded on surrender of the agent's receipt [or Jr. )ated at: _City_.of The_.Co.l_ony Te~$ City of The Colony )n:. 1 0~_~- 9 0 )Name Of Applicant; Same as #! above) ;eliciting Agent: Robert M. Sax '/ ~-'~---~/~' ' Tit)e: City Manager. 0/~(~.,,,"~-,] ,~,, itatement to be Signed by Applicant upon Payment of the Premium or Any Part Thereof HEREBY DECLARE that I have paid to _Robert ~. Sex ~3,606.65 full premium for October 1990 Agent ·Dollars in cash, and that I hold,his/her receipt for same R 902 Rev. 3-87 IApnlicant) AMERITAS LIFE INSURANCE CORP. Lincoln, Nebraska Conditional Receipt ~ceived of Dollars on account of the first ,~mium on proposed Group Insurance for which application is made. This payment is made and accepted subject to the following conditions: Group Insurance at the Company's rates and under the terms of the policy(les) applied for shall take effect as of the date shown in the plicatlon, Section 1 3, if the application is accepted at the Home Office of the Company, But in case the application is not accepted, the yment evidenced by this receipt shall be returned when this receipt is surrendered. te Agent Detach this receipt when payment is made. Item 4: Exclusions: a. Classes, include reason for exclusion, e.g., employees covered by a Dental HMO, Prepaid, etc. b. Locations, if location is different from applicant's, list city and state. Item 5: Subsidiary and/or affiliated companies to be insured: List names and locations, item 1 1: Plan design and Proposed Rates: Name and Title of Person to Receive Correspondence: Katherine Martinez-Personnel Director AdditlonatRemarks: Billing must be separted by departments with their total:~.