HomeMy WebLinkAboutHR14-192 - Original - Standard Insurance Company - Core Life Insurance - 08/01/2014 Records e e
K T Document
WAS HINaTON
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 fume: f, I .
Vendor Number: 3 1- Z E
]D Edwards Number
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Contract Number: _
This is assigned by City Clerk's Office
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Project Name ,; =-
Description: ❑ Interlocal Agreement ❑Change Order ,Q Amendment ❑ Contract
❑ Other:
Contract Effective Date; CJ� -��s-�;�� Termination bate:
Contract Renewal Notice (Days): t
Number of days required notice for termination or renewal or amendment
Contract Manager:(,..)�{rK�-t F, ;L Department:
Detail: (i.e. address, location, parcel number, tax id, etc.);
S:Publlc\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: Dan 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:
Change Dependent Life Premium Contribution to: Composite
Reduce Dependent Life Rate to $.90 from August 1, 2014 - December 31,
2015.
Note: Temporary rate reduction is in lieu of premium refund.
I request that the amendment become effective on August 1, 2014. 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: '1..._.. y --`` Title:
Authorized Representative
Print Name: :-r f - Date:
Standard Online Amendment Request 7/30/2014 1:00 PM