The URL can be used to link to this page

Home My WebLink AboutContract 37690-A5 (2)�IiY $ECRETARV /t c-, ri�iTRACT�...-.,��vt � ,� Request for Group Insurance Amendment Standard Insurance Company 900 SW Fifth Avenue Portland, OR 97204-1282 Employee Benefits Consultant: Lee Lane Employee Benefits Service Representative: Breck Schmidt Employee Benefits Sales and Service Office: Dallas Employer Name: City of Fort Worth Group Number: 644013 As an authorized representative of the Employer, I request that Standard Insurance Company ("The Standard") amend the above Employer's coverage under the Group Policy to make the following change(s): A 1-time open enrollix�.ent will be allowed. Members may enroll in LTD or change their election witlio�st evidence of insurability. A 6/ 12 Pre -Existing Condition Exclusion will apply. I request that the amendment become effective on 1 Ll /2012. I understand that the amendment will not become effective unless approved and issued by The Standard. I request that the amendment be approved by The Standard subject to The Standard's usual underwriting requirements. I understand that the amendment, if approved by The Standard, will be issued in the policy language customarily used by The Standard. I understand that any increase in Insurance for a Member who is not Actively At Work all day on the Member's last regular work day before the scheduled effective date of the amendment will be deferred until the first day after the Member completes one full day of Active Work. I request that the amendment, if approved and issued by The Standard, become effective by its Insurance Amendrr Sign Name: Auth rize Print Name: � � S� t4a u�.�.�.��cu.ia��, v y u.a�. u ++r+v� v+ , +u .. � ..a ..v�J v+ ..+++v . form be attached to and made a part of the amendment. Representative Online Amendment Request cl � r r APf��,�_.... Title: tI,�S �- `-j 7� �Y QV{0-Q_f' Y � r��j�hD� �. Date. � 0 -,�-� � ��. �.�'4 �� T � f l� ld' �i �Lc� t� f!`.'li �",�!�rl �as pope p®� �'� o� 0 or T OnpOv o�oop y a��xA�.oa.� d� VK�C �' � 2/ 15/2011 5:07 PM OFFICIAL RECORD CITY SECRETARY FT. WORTH, TX