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HomeMy WebLinkAboutES05-336 - Amendment - Request - Standard Insurance Company - 2012-2013 Life Insurance Contracts - 11/01/2012 1 40!!:mv-. Records M ern KENT Document WASH INGTON - 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: �� SduZtF�f��Cf- Vendor Number: JD Edwards Number Contract Number: { CS ©-5-- 33 This is assigned by City Clerk's Office Project Name: Description: ❑ Interlocal Agreement ❑ Change Order 'Amendment ❑ Contract ❑ Other: I Contract Effective Date: Termination Date: --""— Contract Renewal Notice (Days): Number of days required notice for termination or renewal or amendment Contract Manager: Department: Tf , Detail: (i.e. address, location, parcel number, tax id, etc.): z KL6 - e4c)mTR+Q� 5•Pubilc\RecordsManagement\Forms\ContractCcver\a dcc7832 1 11/08 Request for Group Insurance Amendment Standard Insurance Company 900 SW Fifth Avenue Portland, OR 97204-1282 Employee Benefits Consultant: David Tappan Employee Benefits Service Representative: Michele Scaglia Employee Benefits Sales and Service Office: Seattle Employer Name: City of Kent Group Number: 339619-E As an authorized representative of the Employer, I request that Standard Insurance Company ("The Standard") include the following in the Employer's Group Policy: Plan 2 (additional) Life: Increase Guarantee Issue to $300,000 (from $50,000), for Members who become eligible on or after March 1, 2013. I request that the amendment become effective on March 1, 2013. 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'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. 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 IZ k7 I et `Au-thonzed Representative PnntName 4P,%KRAwNf- rT-tR`y[.M Date: Standard Online Amendment Request 2/15/2013 5:06 PM