HomeMy WebLinkAboutContract 47856 CITY 9ECRETAW
application
CONTRACT �> � �
ERITAS®
LIFE INSURANCE CORP.
for group dental and/or vision insurance See reverse side for additional information. Lincoln,NE
1. Applicant's legal name City of Fort worth
2. Doing business as
3. 10. Dependent Participation:
P.O.Box/ZIP Code Employer contributes 0 % of dependent premium.
1000 Throckmorton St ❑ Tied-to-Medical (All eligible dependents covered on
employer's medical plan must be insured, except those
Street Address listed under excluded classes or locations.)
Fort Worth, Tx 76102 ❑ Non-Contributory(Policyholder contributes 100% of
City/State/ZIP premiums. All eligible dependents must be insured,
(817) 392-7782 (817) 392-2624 except those listed under excluded classes or locations.)
Phone No. Fax No. ❑ Non-Contributory, except covered elsewhere (If policy-
holder contributes 100% of premiums, all eligible depen-
75-6000528 dents must be insured, except those listed under excluded
E-mail Address Tax I.D. No. classes or locations and those covered elsewhere.)
4. What is the nature of your business or industry? ❑ Contributory (Policyholder is required to contribute to the
employee premium and must contribute at least 25% of
City Government the total employee and dependent premium.)
® Voluntary(Policyholder does not contribute towards
premium, 100% contribution by employee.)
5. Eligibility 11.Section 125 Plan
Total Number of Eligible Employees. . . . . . . . . . 6247
Election Period
Employees in Waiting Period . . . . . . . . . . . . . . . NA
Plan Year
6. Are any classes or locations excluded?. . . . . . .❑Yes N No
Are domestic partners included? . . . . . . . . . . . .®Yes E1 No 12.Employee welfare benefit plans that are subject to ERISA must
satisfy various reporting, disclosure and related obligations.
Are retirees included? . . . . . . . . . . . . . . . . . . . . [:]Yes N No These requirements include the provisioning of a Summary
(If yes, please use reverse side for explanation.) Plan Description or SPD. The certificate of coverage can serve
as an SPD if certain information is additionally disclosed. Please
7. Are any subsidiary and/or affiliated check one of the following(failure to respond shall be consid-
companies to be insured?. . . . . . . . . . . . . . . . .ElYes ®No ered a positive response for A. and a negative response for B.).
(If yes, please use reverse side to list name and location.) A. ❑ Plan is subject to ERISA (complete question 12.B.)
8. How many hours per week ® Plan is NOT subject to ERISA—Church or Govt.
equals full time employment? . . . . . . . . . . . . . 40 employer or other safe-harbor exception
9. Employee Participation (see DOL Reg. §2510.3-1(j))
B. X Applicant requests that Ameritas Life
Employer contributes 0 % of employee premium. Ins. Corp. prepare a SPD for its dental
❑ Tied-to-Medical (All employees covered on employer's and/or vision plan. . . . . . . . . . . . . . . . . .®Yes ❑No
medical plan must be insured, except those listed under If yes, the company is to prepare a SPD. The following
excluded classes or locations.) information is required under ERISA and MUST be
❑ Non-Contributory(Policyholder contributes 100% of included in the SPD.
premiums. All employees must be insured, except those Plan No. Plan Fiscal Year
listed under excluded classes or locations.) Plan Administrator:
❑ Non-Contributory, except covered elsewhere (If policy > Name:
holder contributes 100% of premiums, all employees u
be insured, except those listed under excluded Glasse o 111-i Address:
locations and those covered elsewhere.) LV � � City, State, ZIP
❑ Contributory(Policyholder is required to contribute to theme W Phone No. Plan Fiscal Year
employee premium and must contribute at least 25% of
the total employee and dependent premium.) v >, Please Note:Applicant remains responsible for ensuring
1 .
® Voluntary(Policyholder does not contribute towards that SPD form provided by Ameritas Life Ins. Corp, is
premium, 100% contribution by employee.) V complete and accurate and satisfies applicable laws
and regulations. Moreover, applicant remains respon-
sible for providing its plan participants with SPD updates
as required by applicable law and regulations.
GR 902 Rev.7-07 Page 1 of 3 102308L
13.Waiting Period 16.The following coverages are applied for:
0 for those employed on or before the policy effective Employee & Dependents Benefits
date. ❑Dental ❑Orthodontia ®Eye Care
30 for those employed after the new policy effective date. ❑Other
❑ month(s) ®calendar days ❑working days Employee Only Benefits
14.Effective Date and Termination Date ❑Dental ❑Orthodontia ®Eye Care
® Immediate ❑Other
❑ First of Month Effective date/End of Month Termination date This insurance shall be effective on: 08/01/2016
❑ Other (Premiums due prior to the coverage period.)
17.Policy and Certificate Delivery(select one)
A. eCert*/ePolicy (*generic cert, non-personalized)
15.Premium Payment Mode (In advance) El via PDF format sent via e-mail to:
El Monthly El Quarterly El Semi-Annual ElAnnual
® Payroll Deduction (To choose this option, employee must
pay employee and dependent premium.) ❑ via eService and member portal
If policy effective date is other than first of B. Paper policy/personalized certificates
the month, is a first of the month premium ❑ Initial employees only
due date desired? . . . . . . . . . . . . . . . . . . . . . . .❑Yes ❑No ❑ Subsequently added employees
Billing Options Note:eCert will be available on member portal for all members.
❑Home Office ®Third-Party Administration
18.Insurance requested on this application will replace the
coverage(s) checked.
Contact Name Coverages: ❑Dental ❑Orthodontia ❑Eye Care
Title ❑ Other
Name of Current Carrier
Street Address
Policy No.
City/State/ZIP ❑ Coverage applied for is replacing comparable coverage
now or previously in force with another carrier.
Phone No. Fax No. ❑ It is intended that the insurance coverage applied for be
in addition to, supplemented by, or supplemental to any
E-mail Address similar coverage now in force, or to be in force, with this or
any other carrier.
Termination Date Original Effective date
Item 6: Exclusions
a. Classes, include reason for exclusion.
Temporary, seasonal and part time employees who work fewer than 20 hours per week.
b. Locations, if location is different from applicant's, list city and state.
Item 7: Subsidiary and/or affiliated companies to be insured. List names and locations.
Plan Design and Proposed Rates:
Additional Remarks:
GR 902 Rev.7-07 Page 2 of 3 102308L
Agreements
This application will be subject to review and approval by the Home Office of Ameritas Life Insurance Corp.If this application is accepted,
the final rates and benefits will be based on verification of this information and final enrollment numbers. This applicant represents
that he/she has read the statements and answers to the above questions and that they are complete and true to the best of his/her
knowledge and belief.Any policy including riders issued as a result of this application will,with this application, be the entire insurance
contract. If this application is accepted at the Home Office of Ameritas Life Insurance Corp., group insurance at the Company's rates
and under the terms applied for shall take effect as of the date set forth in the policy. If this application is not accepted, any premium
advanced shall be refunded.
Statements
In several states, we are required to advise you of the following: Any person who knowingly and with intent to defraud provides
false, incomplete, or misleading information in an application for insurance, or who knowingly presents a false or fraudulent claim
for payment of a loss or benefit, is guilty of a crime and may be subject to fines and criminal penalties, including imprisonment.
In addition, insurance benefits may be denied if false information provided by an applicant is materially related to a claim. (See
state-specific statements.) • Note for California Residents: California law prohibits an HIV test from being required or used by health
insurance companies as a condition of obtaining health insurance coverage. For group policies issued,amended,delivered or renewed
in California,dependent coverage includes individuals who are registered domestic partners and their dependents. • Note for Colorado
Residents: It is unlawful to knowingly provide false, incomplete, or misleading facts for information to an insurance company for the
purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and
civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading
facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant
with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within
the Department of Regulatory Agencies. • Note for Florida Residents:Any person who knowingly and with intent to injure, defraud or
deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of
a felony of the third degree. • Note for Georgia, Kansas, Nebraska, Oregon, Vermont and Virginia Residents: Any person who, with
intent to defraud or knowing that he is facilitating a fraud against insurer, submits an application or files a claim containing a false or
deceptive statement may have violated state law. • Note for Kentucky Residents: Any person who knowingly and with intent to defraud
any insurance company or other person files an application for insurance containing any materially false information or conceals,for the
purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime. • Note
for New Jersey Residents: Any person who includes any false or misleading information on an application for an insurance policy is
subject to criminal and civil penalties. • Note for New Mexico Residents: Any person who knowingly presents a false or fraudulent
claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and
may be subject to civil fines and criminal penalties. • Note for Pennsylvania Residents: Any person who knowingly and with intent to
defraud any insurance company or other person,files an application for insurance or statement of claim containing any materially false
information or conceals for the purpose of misleading information concerning any fact material thereto commits a fraudulent insurance
act, which is a crime and subjects such person to criminal and civil penalties.
❑ If you do not want your company name used by Ameritas Life Insurance Corp. in our effort to recruit PPO providers,
check this box.
Signed at: City 60y-� aI)D Yu State �TQXQ S Date s l--_�P LO /;
Signed by: (Policyholder Representative)
Printed name and title 64_n SSIS�-a t
Signature
Solicitin t: I understand and agree that if I'm not already appointed with Ameritas Life Insurance Corp., I must apply to and be
appointed with Ameritas before I present this product to any client.
Printed Name For FL agents only, provide FL license#
Signature
OFFICIAL RECORD
The policy provides dental and/or vision benefits only. Review your policy carefully. CITY SECRETARY
Was a binder check received? ❑Yes ❑No If yes, then amount$ FT:
Check received by (agent) Authorized by(policyholder)
8° 16,
ALL PREMIUM CHECKS MUST BE MADE PAYABLE TO AMERITAS LIFE INSURANCE CO g° off $
ECKS PAYABLE TO THE AGENT OR LEAVE PAYEE BLANK. , °
APPROVED AS TO FORM f��( f'� o, oo°� 1�.
GR 902 Rev.7-07 _ Page 3 of 3 'e0oaDUab° L
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