HomeMy WebLinkAboutES05-336 - Amendment - Request - Standard Insurance Company - 2005 - 2007 Group Long Term Disability Insurance Policy - 07/01/2005 __ §4M7gP�ltv�
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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 Clerks Office.
Vendor Name: �—ni D RA_1� Vendor Number: 53411399-7+
JD Edwards Number
Contract Number:
This is assigned by Deputy City Clerk
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Detail: I�GIJYY�uN.� T2f4T�1�. (� C'770
Project Name:
Contract Effective Date: t1 rn IT- . Termination Date:
Contract Renewal Notice (Days):
Number of days required notice for termination or renewal or amendment
Contract Manager: Department:
Abstract:
S Public\RecordsManagement\Forms\ContractCover\ADCL7832 07/02
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 Michele Scaglia
Employee Benefits Sales and Service Office: Seattle Group Office
Employer Name City of Kent
Group Number 339619 - Life and AD&D
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)
Please change Definition of a Member to read:
All employees who are regular full and part time and work at least 21 hours per
week and employees in job share position working at least 20 hour per week.
Please change Eligibility Waiting Period to read:
Date of hire
I request that the amendment become effective on July 1, 2005 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 ((��Jet'! t"L �12'C�JL7t2
Authorized Repeslentahve l
Print Name• 6 Ll� �L ( S Jr-TL4 Date
Standard Online Amendment Request 9/29/2005 10:44 AM