HomeMy WebLinkAboutContract 42699CITY sECRernRY� �/6
CONTRACT NO..
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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
Employee 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 12/31/2012.
I. The Premium And Renewal portion of the Coverage Features is amended to
provide the following:
Premium Due Dates: January 1. 2011 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
3. 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.
I request that the amendment become effective on 07/01/2011. 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.
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Standard Online Amendment Request CITY SECRETARY OFFICIAL RECORD 7/27/2011 4:49 PM
i N FT. WORTH, TX
I understand that any increase in Insurance for a Member who is not Actively At Work
all day on the Members 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 Name:
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APPROVED AS TO
FlIn LEGALITY:
ASSItTANTY,ITY ATTORNEY
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Date:
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OFFICIAL RECORD
CITY SECRETARY
FT. WORTH, TX
Standard Online Amendment Request 7/27/2011 4:49 PM