HomeMy WebLinkAboutES05-336 - Amendment - Request - Standard Insurance Company - 2013-2014 Long Term Disability Insurance Contract - 04/01/2013 Records Ma*-ageme3�n- I%,
KENT Document
WASHINGTON
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: �'Fin,rqt�,e;--Rz L i F t- A3ct—
Vendor Number: y 953
JD Edwards Number
Contract Number: Esau 3434
This is assigned by City Clerk's Office
Project Name: Lbw c, I 12m 171�i4P51 LlT`( PrVYI D m "i-
Description: ❑ Interlocal Agreement ❑ Change Order IJAmendment ❑ Contract
❑ Other:
Contract Effective Date: y-01 ' 13 Termination Date-
3 -OI - 1`f
Contract Renewal Notice (Days):
Number of days required notice for terminat on or renewal or amendment
Contract Manager:-Z=�, Department:
Detail: (i.e. address, location, parcel number, tax id, etc.):
TRIG uA1 Lo�Ga�y �Pr`f iu Il i2 �� i fie. E�F F
S Pub IIC\RecordsManagement\Forms\ContractCover\adcc7832 1 11/08
Request for Group Insurance Amendment
Standard Insurance Company
900 SW Fifth Avenue
Portland, OR 97204-1282
Employee Benefits Consultant: Daniel Feldman
Employee Benefits Service Representative- Michele Scaglia
Employee Benefits Sales and Service Office: Seattle
Employer Name: City of Kent
Group Number: 339619
As an authorized representative of the Employer, I request that Standard Insurance
Company ("The Standard')include the following in the Employer's Group Policy.
Effective April 1, 2013:
Include Longevity Pay in Pre-disability Earnings on LTD and in Annual
Earnings on Life
Effective March 1, 2014:
Amend Item i of Deductible Income to read as follows:
1. Sick pay, annual or personal leave pay, severance pay, or other
salary continuation, including donated amounts, (but not vacation pay)
paid to you by your Employer, if it exceeds the amount found in a., b., and
c., provided that your bargining agreement (or similar agreement or
understanding) requires that you remit payment to your Employer or sick
leave bank for such pay.
Add to Exceptions to Deductible Income:
Sick leave pay and donated/ shared leave pay paid to you by your Employer
if your bargaining agreement (or similar agreement or understanding)
requires that you remit payment to your Employer or sick leave bank for
such pay.
I request that the amendment become effective on the applicable dates shown above. 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
Standard Online Amendment Request 3/10/2014 10:54 AM
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 n,
Sign Name: itle. /r'l.
ut or e Representativ/e/ /7
Print Na
Gci '� �-e l 294e' Date. 3 8
Standard Online Amendment Request 3/10/2014 10:54 AM