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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