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HomeMy WebLinkAboutES05-336 - Other - Standard Insurance Company - Application for Group Long Term Disability Insurance Policy - 07/01/2005 Records Man-'a'gemem� Ns: KENT DocumentWASHINGTON CONTRACT COVER SHEET This is to be completed by the Contract Manager prior to submission to City Clerks Office. All portions are to be completed, if you have questions, please contact City Clerks Office. Vendor Name: %SI-Pr&�DnQ a�jt? Vendor Number: JD Edwards Number Contract Number: aC,5"-33(0 This is assigned by Deputy City Clerk Description: r*0o5 - a 1 i m t, a00,7 L7t> CONlll-1 &ex Detail: _Cf`I�LlG1I 1�N TO f�' `l,C`L C l'� l'a Project Name: Contract Effective Date: �11t`i _ �ObS Termination Date: Contract Renewal Notice (Days): oo Number of days required notice for termination or renewal or amendment Contract Manager: iE�� Department: lS Abstract: S Public\RecordsManagement\Forms\ContractCover\ADCL7832 07/02 STANDARD INSURANCE COMPANY Application for Group Insurance Employee Benefits- Underwriting 900 SW Fifth Ave Portland, OR 97204-1282 Please type or print REQUESTED EFFECTIVE DATE 07/01/05 APPLICANT Full Legal Name of Group(Exactly as it is to be shown in the policy) City of Kent Street Address 220 4th Ave S City Kent State WA Zip Code 98032 Phone Number ( 253 )856-5290 FAX Number ( 253 ) 856-6270 Group Contact Becky Fowler Contact's Title Benefits Manager Contact's Phone No if different ( ) Contact's FAX No if different ( ) Nature of Business municipal employer INSURANCE COVERAGE REQUESTED a ❑ Life Only ❑ Supplemental Life ❑ Dental/Employees [J1 LTD ❑ ❑ Life&All ❑ Additional/Optional Life❑ Dental/Employees and Dep(s) ❑ STD ❑ ❑ Dependent Life ❑ Stand Alone AD&D ❑ Dental/Orthodontia ❑ LTD with Transitional Duty Agreement OTHER INSURANCE A Does this insurance supplement other insurance? ❑Yes 0 No If yes, specify for each line of coverage and Insurance Carrier B Does this insurance replace existing insurance2 [A Yes ❑No If yes, specify for each existing line of coverage LTD-Assurant Employee Benefits • Please submit a copy of each in force policy, certificate or plan document Effective date of Prior Plan 07/01/03 Termination date of Prior Plan 06/30/05 ACTIVE WORK REQUIREMENT:A person must meet an Active Work requirement to become insured Members who have not met an Active Work requirement are not insured until returning to work for one full day and meeting all other contractual requirements Initial: Note Some members who do not meet an Active Work requirement may be eligible for Waiver of Premium with a prior carrier The Active Work requirement does not apply to Dental coverage APPLICANT AGREES THAT-I hereby apply for Group Insurance as provided in the attached proposal. The above information is true and correct to the best of the Applicant's knowledge and belief It forms the basis for this request for group insurance If the requested insurance is acceptable to Standard Insurance Company under its current rules and practices and is legally permissible, a Group Policy will be issued in the language customarily used by Standard It will be effective on the date determined by Standard No producer has the authority to guarantee the acceptability of the requested insurance Standard may issue separate Group Policies if more than one coverage is requested in this Application The insurance,if approved,will be subject to Standard Insurance Company's usual underwriting requirements, including the exclusions and limitations in the Group Policy , and, if applicable, Evidence Of Insurability The effective date of insurance for which a person is required to submit satisfactory Evidence Of Insurability will be determined in accordance with the terms of the Group Policy,subject to the Active Work requirement No premiums will be collected or paid by the Applicant for such insurance until notification of approval No material describing coverage under the Group Policy will be distributed by the Applicant to any person to be insured without the prior written consent of Standard Insurance Company Premium rate quotations were based on data submitted to Standard Final premium rates will be determined by the actual composition of the group The consideration for any Group Policy which may be issued is this Application and the payment of premiums Payment of premium after receipt of the Group Policy is acceptance of the terms of the Group Policy This Application, including the attached proposal, is made a part of the Group Policy Applica uthorizes the produce b r record,or consultant to receive information regarding the applicant's claims status and experience that the ppli anthas a righ h is reasonably necessary to assist the applicant in conducting a review of the information. Si r aA Titibo pl cant uthorized Representative VW Signature of Wit ss Signature of Licensed Producer(where required by law) Date License # (Must be signed prior to the requested effective date) Initial Deposit$ 16 , 6 3 8. 0 0 SI 08-7364 1 of 2 (12/03) STANDARD INSURANCE COMPANY Receipt for Initial Deposit Employee Benefits- Underwriting 900 SW Fifth Ave Portland,OR 97204-1282 Received from I T Y ©F YtJ,i-r an Initial deposit of $ li.105%09 * in connection with the Application for Group Insurance bearing the same date as this conditional receipt Date This receipt is subject to the terms and conditions below. Received By Name Title *All premium checks must be made payable to Standard Insurance Company Do not make check payable to the producer or leave payee blank Terms of Receipt(Please read carefully.) If the requested insurance is acceptable to Standard Insurance Company under its current rules and practices and is legally permissible, a Group Policy will be issued in the language customarily used by Standard It will be effective on the date determined by Standard No producer has the authority to guarantee the acceptability of the requested insurance Standard may issue separate Group Policies if more than one coverage is requested in this Application The insurance,if approved, will be subject to Standard Insurance Company's usual underwriting requirements, including the exclusions and limitations in the Group Policy and, if applicable, Evidence Of Insurability The effective date of insurance for which a person is required to submit satisfactory Evidence Of insurability will be determined in accordance with the terms of the Group Policy, subject to the Active Work requirement No premiums will be collected or paid by the Applicant for such insurance until notification of approval No material describing coverage under the Group Policy will be distributed by the Applicant to any person to be insured without the prior written consent of Standard insurance Company Premium rate quotations were based on data submitted to Standard Final premium rates will be determined by the actual composition of the group The consideration for any Group Policy which may be issued is this Application and the payment of premiums Payment of premium after receipt of the Group Policy is acceptance of the terms of the Group Policy This Application, including the attached proposal, is made a part of The Group Policy SI 08-7364 2 of 2 (12t03) General Worksheet — One Policy# 91At��1ARp 1 iIi1TM f 415tiiGnyj SIC Code Name of Group City of Kent Exactly as it is to be shown in the policy State of Issue WA Zip Code 98032 ChentlD/Prospect# Group Rep Service Rep Office FORM OF ORGANIZATION Check the appropriate box ❑ Association ❑ Limited Liability Company ❑ Other, Describe municipal employer ❑ Corporation ❑ Partnership ❑ Sub-Chapter-S Corporation ❑ School Districts ® Government Unit/Public Unit ❑ Sole Proprietorship (Federal, state, county, city, some hospitals, etc) ❑ Trust (Please include trust document) ❑ Labor Union (Please include the collective bargaining agreement) AFFR IATES Please provide full legal names(exard)its they are to be shown in the polny),location,nature of business List any affiliates to be excluded DEFINITION OF A MEMBER A Describe the persons to be insured Include separate descriptions if they vary by coverage If different by line of coverage, please specify on corresponding worksheets in Comments&Special Requests section ❑ All active employees and partners(if a partnership)regularly working 30(or )or more hours per week ❑ All active employees and partners(if a partnership)regularly working 30 or more hours per week that participate in the employer sponsored medical plan ® Other (Specify`Hours Per Week"requirement) All employees who are regular part-time or regular full-time and work at least 21 hrs/wk and employees in a Job NOTE Enrollment cards of a pnor carrier and/or beneficiary designations on forms other than The Standard's will not be accepted unless the Applicant submits a written request, together with a copy of all forms to be approved, and we approve the Applicant's request in writing CONTRIBUTIONS Complelc!kv appro/male boxes far each coverage bang regttesled Life Dental Dental Stand TDB/ Life With Dep Supp'I Addl STD LTD for for Ortho Alone DBL/ AD&D Life Life Life Ee's Dep AD&D UCD A Employer Pays Total Premium B.Percentage of Premium Employee Pays % % % % % % 0`y> % % % % % 1 Number Eligible 2 Number Enrolled 3 Participation%Required C Premiums included in gross earnings Edition# Attachments 51 7372 1 of 2 General Worksheet — One POLICYHOLDER CORRESPONDENCE AND CONTACTS Executive Correspondent (for formal notices) Administrative/Claims Contact: ❑ Mr ❑Mrs W1 Ms ❑ Same as ❑ Executive ❑Billing Name Becky Fowler Q Other Fill out below: Title Benefits Manager Name Ellen Mak Phone ( 253 ) 856-5290 Title HR Analyst Fax ( 253 ) 856-6270 Phone ( 253 ) 856-5297 Address ®Same as Policyholder's. ❑Other Fill out below Fax ( 253 ) 856-6270 Address Bllling: ®Same as Executive Correspondent E-Services Administrator: ❑Other.Fill out below, Same as [;6 Executive ❑ Billing ❑Admin/Claims Name ❑ Other. Fill out below: Title Name Phone ( ) Title Fax ( ) Phone ( ) Address Email Address Address Document Delivery Options Shipping Address for Printed Certdicates (This information is needed ONLY if printed ❑ E-Contract Documents via Admm Ease(W) certificates are requested Do not use a PO Box,Certificates are shipped via UPS) (includes Policies, Amendments, Certificates Administrative Contact Notices, etc) ❑ Broker (include street address below) ❑ Certificates via E-Mail to Group Office(E) ❑ Certificates via Diskette (D)to Group Office ❑ Group Office ❑ Other SUMMARY PLAN DESCRIPTION A ERISA requires Summary Plan Descriptions(SPDs)for employee benefit plans other than church or government employers The Certificate can serve as an SPD if certain plan information is added to it You may meet ERISA requirements by having a combined Certificate and SPD If the employer has an SPD,attach it for review If the employer does not have an SPD, provide plan information to add to the Certificate Please check one of the following ❑ ERISA information below ❑ SPD attached WJ Not subject to ERISA—Church or Gov't Employer Complete B-H for Review Complete G only The following information is required by ERISA and MUST be included in combined SPDs/Certificates B. 9 digit Employer Tax Identification Number assigned by IRS 41 - 6001254 C Plan number assigned to each line of coverage by Policyholder(e g 501, 502) Life STD LTD Dental (Also Specify Coverage) D. Plan Year Ends on Month Day E. Plan Administrator/Plan Fiduciary (can be Policyholder) ® Same as Policyholder name, address and telephone number ❑ Other Fill out below Name Street Address, Phone No ( ) City State Zip F Registered Agent for the Service of Legal Process ® Same as Plan Administrator name,address and telephone number ❑ Other Fill out below Name Street Address Phone No ( ) City State Zip G Are there any relevant Collective Bargaining Agreements? ❑ No ❑ Yes(d yes,please attach a copy of the pertinent sections) H Plan Trustee(s) City of Kent Si 7372 2 of 2 (8/01) General Worksheet- Two Name of Group City of Kent Policy# ELIGIBILITY WAITING PERIOD A There are two options for persons employed on the proposed effective date Check one ❑ All are eligible immediately,regardless of length of service ® Only those who have satisfied the waiting period selected below are eligible Others must serve the balance of the waiting period (Please provide hire dates for all employees on enrollment cards or census) B. A new employee must be actively employed for the specific period checked below before becoming eligible for coverage ❑ First day of the month coinciding with or next following days as a Member ❑ First day after days as a Member ❑ First day of the month coinciding with or next following becoming a Member ® No waiting period ❑ Tied to medical plan Medical plan waiting period days ❑ Other DEFINITION OF EARNINGS Earnings definition will automatically include base salary,commissions averaged over 12 months,shift differential pay, Internal Revenue Code 401(k), 403(b),or 457 deferred compensation,executive nonqualified deferred compensation and contributions to fringe benefits under an Internal Revenue Code Section 125 plan 408P earnings will be included in LTD and STD only,and partnership earnings will always be included except for public groups A ® Normal wording as stated above ❑ All of the above items except commissions. ❑ Base salary only(does not include commissions or shift differential) ❑ S-Corporation/Limited Liability wording a If any other compensation is to be included or excluded,describe' ❑ Include bonuses averaged over 36 months Bonuses included on census? ❑ Yes ❑ No ❑ Other Describe C If more than one coverage is requested,it will be assumed that the same definition of earnings will apply to all coverages,unless marked below ❑ Definition of earnings will vary by coverage Describe SECTION 125 PLANS Which coverages are offered through a Section 125 Plan? N/A Which coverages are "core"or"required" benefits? Please provide"cafeteria"enrollment materials/menu to ensure proper administration of benefits COMMENTS&SPECIAL REQUESTS: Eligible Classes All employees who are regular part-time or regular full-time and work at least 21 hours per week and employees in a fob-share position working at least 20 hours per week,excluding Uniformed Officers,Firefighters,and Assistant Fire Chiefs Note Uniformed Officers are defined as Officers and Sergeants or"Police Officers"and Captains and Lieutenants or"Police Admin" See attached list of AFSCME union members paying premiums on a post tax basis SI-7373 1 of 2 (8/00) General Worksheet - Two Estimated Premium Life AD&D STD LTD Dental In force policies with The Standard # 339619 # 100394 # # Match in force policy ❑ INSTALLATION check one ® Home Office with Policyholder ❑Group Office Pool# Grace Period Notice of Rate Change Premium Mode Z Monthly ❑Other BROKER/COMMISSION INFORMATION Commission Scale 1 Broker Douglas Evans ❑ Level-graded(non-Dental) Brokerage R L Evans Company,Inc ❑ Dental Level-graded❑ Dental HMO Address 600 Stewart St,Suite 1210 Seattle,WA 96101 ❑ None City Seattle State WA Zip Code 98101 Please complete the question below Telephone ( 206 ) 448-7878 Tax I D/Social Security 91-0849754 Is the broker receiving a fee for service? ACI 100% %Split Commissions paid to ❑ Individual ®Firm ❑ Yes ® No V1 Resident Agent ❑ Non-resident Agent ❑ Other Already appointed with The Standard 2 Yes ❑ No 2 Broker Brokerage Address City State Zip Code Telephone I—) Tax I D/Social Security ACI %,Split Commissions paid to ❑ Individual ❑Firm ❑ Resident Agent ❑ Non-resident Agent Already appointed with The Standard ❑Yes ❑ No If a Third Party Administrator is involved,please provide the information below and include a copy of the license. Name TPA Services being provided Address: ❑ Billing ❑ Collection ❑ Solicitation City ❑ Other Describe State Zip Code Note TPA licensing may be required if involved in premium processing Telephone ( ) License# Drafting Notes ❑ Hidden Schedule ❑ Separate Carts for Changes. Eff Date of Changes: Changed by: SI 7373 2 of 2 W00) Contract 2000 LTD Worksheet SHADED AREAS—Home Office use only Policy No. S.D.B. Sold Rate No of Lives Name of Group City of Kent Effective Date: Renewal Date: LONG TERM DISABILITY COVERAGE DESCRIPTION (For Contract 2000 Only) A. LTD Schedule of Insurance(if buy up,use#1 for core and#2 for additional) Benefit Waiting Description of Class LTD Benefit Schedule Period Maximum Benefit Period 1 66 %of first$ 10,500.00 ❑ 30 days 2 to age 65 of monthly Predisability Earnings, ❑ 60 days 61 Standard Grading $ 7,000.00 Maximum LTD Benefit VI 90 days ❑ Optional Grading 5770 %of all sources,if applicable ❑ 180 days ❑ 2 yr ❑5 yr ❑SSNRA ❑ Other ❑ Other 2 %of first$ ❑ 30 days ❑ to age 65 of monthly Predisability Earnings, ❑ 60 days ❑ Standard Grading $ Maximum LTD Benefit ❑ 90 days ❑ Optional Grading 5770 %of all sources,if applicable ❑ 180 days ❑ 2 yr ❑5 yr ❑SSNRA ❑ Other ❑ Other B. Social Security Offset V1 Full Offset(Primary and Dependent) ❑ Primary Offset Only ❑ Primary with %Dependents cap (Partial Dependents Offset) C. LTD Underwriting Information Are Members eligible for income from any of the following sources if they become Disabled9 VI Social Security or similar plans 0 Public Employees Retirement System Benefits ❑ State Teachers' Retirement System Benefits ❑ State Disability Income Benefits(UCD,SDI,TDB,TDI,DBL,or other) Shared Leave (see attached) ❑ Other pension, retirement or disability benefits �] No offsets for sick leave or Workers'Compensation Benefits shared leave until afte Sick Leave Offset ❑ 100%backdoor ❑None ❑Full—Member Choice ❑Full—No Choice months D. Recovery ❑ Remove Subrogation and 3rd party E. Definition of Disability ❑ To age 65 own occ List classification(s) ❑ Partial Plus(no carve out availability) (tJ year own occ for ❑All ❑ Other ❑ Other Describe ❑ 2 year own Specialty for ❑Attorneys ❑ Physicians LTD continued on next page. SI 8719 (6/01) Contract 2000 LTD Worksheet (cont.) F. Other Plan Options GQ LTD Conversion $5,000 ❑ Automatic 5%Maximum LTD Benefit increase ❑ Cola% ❑All Employees If not,list classification(s) ❑ Survivor Benefit Removal ❑ ALB ❑ 80% Income Replacement ❑ 100%Income Replacement ❑ Medical Expense Benefit(Not available on Buy-ups) ❑$100 or ❑$200 ❑ 12 months or ❑24 months ❑ Lifetime Security Benefit(Not offered with Conversion/Portability) ❑ Housing Assistance Benefit ❑ Medex Travel Assist ❑ Transitional Duty Package ❑ Horizon Care—EAP ❑ Internet only ❑ Internet&Phone only ❑ Internet, Phone&1-3 Face to Face Consultations #of lives Over 1000 lives rate $ G. Optional LTD Benefits ❑ EAP ❑Telephone Only ❑In Person Service ❑ EIP %of 1st$ ,$ Maximum LTD Benefit Benefit Waiting Period days Maximum Benefit Period months Key employees covered ❑ PCB %of 1st$ ,$ Maximum LTD Benefit %Employer Contribution %Employee Contribution ❑ HIV %of 1st$ ,$ Maximum LTD Benefit ❑ Physicians or Dentists ONLY ❑ Include nurses and other health care professionals ❑ Return To Work Incentive—24 months ❑ Child Care Expense—(Expense period will match RTW period) H. Limitations ❑ 12 months for all limitations ❑24 months for all limitations Add musculoskeletal/connective tissue disorders condition ❑ Remove subjective limitations ❑ Remove Drug&Alcohol ❑ Remove Mental Nervous ❑ Remove prudent person requirement for MD's and attorneys I. All Insurance Offsets ❑ Direct Offset ❑ 60°%Backdoor ❑ 80%Backdoor S18719 (8/01) 06/09/2003 16:52 2538566270 EMPLOYEE SERVTrES PAGE 02 CITY OF KENT POLICY NUMBER: 3.4 EFFECTIVE DATE: April 1, 1996 SUBJECT: SHARED LEAVE SUPERSEDES: ecember 1 9 APPROVED rayorite, M oP LICY: It is the policy of the City of Kent to allow regular employees to donate a portion of their accrued annual leave time to another City employee who has either been called to full time active military duty or who is suffering from a catastrophic illness, injury, impairment, or physical or mental condition that has caused or is likely to cause the employee either to take leave without pay or to terminate his/her employment. It is the intent of the City that this program not be a gifting program and the City incur no additional cost excluding administrative costs 3.4.1 ELIGIBILITY: A. DoneeLRecipient -An employee may be eligible for Shared Leave if he/she meets all of the following criteria. 1. The employee must be a regular employee as defined in the Employee Definitions Policy. 2. The employee has or will soon exhaust all his/her accrued leave balances and is not entitled to industrial insurance compensation or LEOFF I disability leave. 3. The employee's absence from work is as a result of one of the following: a. The employee is on an approved medical leave of absence; b. The employee is suffering from a serious health condition which disables the employee from performing the essential functions of his/her position, as defined b P Y FM LA; C. The employee's presence is required to care for an immediate family member who is suffering from a serious health condition, as defined by FMLA. B. Donor-Regular employees may donate annual leave In one (1) hour increments to an employee who is authorized to receive shared leave as provided in this policy. All donations of annual leave shall be voluntary. p' � vd 3.4 -Page 11 of 2 06/09/2003 16:52 25385F6270 EMPLOYEE SERVICES PAGE 03 SHARED LEAVE NUMBER 3 4 U 34.2 REQUEST& APPROVAL A. Reavest for S bared Leave - Employees requesting Shared Leave donations must submit a written request to the Human Resources Director for approval In the case of an emergency where advance notice is not possible, a written request must be made as soon as practicable. In such emergencies, a representative of the Human Resources Department may make the request in place of the employee B. Review and Approval -The Human Resources Department will review all employee requests, approve and monitor to insure equitable treatment for all employees of the City. Inappropriate use or treatment of these shared leave provisions may result in the denial or cancellation of shared leave. 3.4.3 ADMINItiSTRATION1 A. Valuation -Annual leave shall be transferred on a dollar-for-dollar basis, The value of the leave shall be determined at the current hourly wage of the donor and the donee. B. Computin4 -The Finance Department shall be responsible for computing the values of shared leave, and for adjusting the accrued leave balances. Records of all leave time transferred shall be maintained by the Finance Department. C. Police and Fire-When reviewing Police or Fire Department employees, the Police Chief or the Fire Chief may also consider whether additional adequate time off will be provided through shift trades and/or other leave types unique to those departments. D. Liuman Resources Department shall have the authority to adopt interpretive policies consistent with and applicable to employees covered under this shared leave program to the extent necessary for the proper and efficient administration of this program E. Finance Department will be responsible for monitoring donee leave usage balances. At no time will shared leave or other leave use exceed the one hundred eighty (180) calendar days allowable under the City's Leave of Absence Policy. 3.4.4 COLLECTIVE BARGAINING AGREEMENTS/CIVIL SERVICE LAWS: Employees covered by Collective Bargaining agreements, Civil Service Laws and rules, or covered by the Law Enforcement Officers and Firefighter's (LEOFF 1) disability provisions will be subject to the specific terms or those agreements, laws or rules applicable to shared leave arrangements and are excluded from the provisions of this policy. In the event such collective bargaining agreements, laws or rules do not contain shared leave provisions, then employees covered by same Y411 be governed by this policy, v:lponGealshaedlv.pa 3.4 - Page 2 of 2 Employees paying their own LTD premium as of 4/13/05 Name Address Numl Employee Deduction Begin Date Aguilar Jr, Esteban 45198 1321 6/1612003 Curtis, Suzan R 45690 157 12/16/2003 Hastings, Lori A 45969 557 6/16/2003 Hoopes, Brigitte R 46043 1649 6/16/2003 Jenkins, Bernard 46085 1321 6/16/2003 Kinsella, Jill L 46163 1321 6/16/2003 Knapp, Sheila P 46170 157 6/16/2003 Kulin, Scott A 46190 1321 6/16/2003 Langsea, Joel D 46201 1321 6/16/2003 Martinez, Manuel A 46309 157 6/16/2003 Michael, Dan L 46384 15.7 6/16/2003 Perkins-White, Mary E 45025 1321 6/16/2003 Phiel, Madelyn A 45042 11 73 6/16/2003 Stone, Marilyn J 45308 157 6/16/2003 Swanson, Mallone L 45333 1321 6/16/2003 Ward, Christopher P 45451 1321 6/16/2003 Warren, Shelley W 45456 1422 12/16/2003