HomeMy WebLinkAboutES05-336 - Amendment - Request - Standard Insurance Company - 2009-20010 Group Long Term Disability Insurance Policy - 04/01/2009 y
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KENT Document
W�SHINGTOH
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 Clerk's Office.
Vendor Name: �'1 A1•�1�(l��� .1 (� L 1 '.�
Vendor Number:
JD Edwards Number
Contract Number: C-5Z - --336
This is assigned by City Clerk's Office
Project Name:
Description: �Unterlocal Agreement ❑ Change Order EyAmendment ❑ Contract
❑ Other:
Contract Effective Date: Termination Date:
Contract Renewal Notice (Days):
Number of days required notice for termination or renewal or amendment
Contract Manager: H Department:
Detail: (i.e. address, location, parcel number, tax id, etc.):
S,Publlc\RecordsManagement\Forms\ContractCover\ada7832 1 11/08
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TheStwrd
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Request for Group Insurance Amendment
Standard Insurance Company
900 SW Fifth Avenue
Portland, OR 97204-1282
Employee Benefits Consultant: Dave Tappan
Employee Benefits Service Representative: Tiffany Philips
Employee Benefits Sales and Service Office: Seattle Sales & Service
Employer Name: City of Kent
Group Number: 339619
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):
- Re-write the LTD as an Enhanced LTD
- Benefit duration to reflect SSNRA
I request that the amendment become effective on April 1, 2009 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-existmg 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'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.
Standard Online Amendment Request 3/24/2009 9:58 AM
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 Title:
A riz d Representative
Print N ILC Date:
3o
Standard Online Amendment Request 3/24/2009 9:58 AM