HomeMy WebLinkAboutContract 37690-A3 (2)CITY SECRETARY
coNTRACT No. �'1 t9 o A73
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Request for Group Insurance Amendment
Standard Insurance Company
900 SW Fifth Avenue
Portland, OR 97204-1282
Employee Benefits Consultant: Lee Lane
Employce Benefits Service Representative: Breck J. Schmidt
Employee Benefits Sales and Service Office: Dallas
Employer Name: Fort Worth City Of
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):
Group Request to extend their current renewal through 12/3I/2010.
i. The Premium And Renewal portion of the Coverage Features is amended to
provide the following:
Premium Due Dates: July 1, 2010 and the first day of each calendar
month thereafter. Premium Rates will be
calculated based on the Age of Member On Last
January 1.
2. The Predisability Earnings section is amended to read as follows:
PREDISABILITY EARNINGS
Predisability Earnings means the greater of;
1. Your monthly rate of earnings as reported on July 1st (representing the prior
year's income) that will be used for determining your benefits under your
Employer's retirement plan;
2. Your current hourly rate of earnings in effect on the prior July 1st; or
L Your current hourly rate of earnings if you become a Member after July 1st.
Any change in your Predisability Earnings after your last full day of Active Work
will not affect your LTD Benefit,
Standard Online Amendment Request
RECoRn
CITY SECRETARY E
FT, WORTH. TX r
6/25/2010 11:53 AM
I request that the amendment become effective on 07/01/2010. 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, including, if applicable, Evidence of Insurability or a
Pre-existing Condition provision.
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 Is 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 terms without any further acceptance by the Employer, and that a copy
of this Request for Group Insurance Amendment form be attached to and made a part
of the amendment,
Sign
Authorized Representat
Print Name: Karen L. Montgomer
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ALITY:
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Attested byo
Standard Online Amendment Request
Assistant City Manager
Hate:
WORTH, T1{
6/25/2010 11;53 AM
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Memorandum
DATE: July 145 2010
TO: Karen Montgomery, Assistant City Manager
Denis McElroy, Assistant City Attorney
City Secretary 40(000
FROM: Margaret Wise, Assistant Director/Human Resources
THROUGH: Karen Marshall, Human Resources Director
SUBJECT: Change LTD Plan effective date for annual enrollment
Attached for your signature is an amendment from The Standard extending the current renewal
through December 31, 2010 and a change to the plan's effective date to January I". beginning
January 1, 2011. This amendment is in keeping with all benefit plans having a January lst
effective date as approved by the ERP advisory committee. The plan change is effective July 1,
2010.
The amendment is stating that the current terms will be extended to December 31, 2010. Each
year beginning January 1, 2011, Benefits will perform the annual enrollment for LTD which
consists of calculating premium changes for the participants. The participants' annual earnings
will be based on the previous July 1A date and age as of January I" ; those participants whose
age and/or earnings put them in another quadrant will have a premium increase effective
January 1.
Thank you for your immediate attention.
C: Karen Marshall, Human Resources Director
Attachment: The Standard, Request for Group Insurance Amendment
Routing Slip
Change LTD Plan effective date for annual enrollment
Route: Signature Date
Law Department
19
Review as to Foam
DVVI
r/
City Manager's Office
Approval
>�l/D
JUL 2 20
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