HomeMy WebLinkAboutHR18-161 - Amendment - CIGNA - Basic Group Life Insurance Policy #FLX-968145 - 01/01/2021ApprovalOriginator:Department:
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Agreement Routing Form
For Approvals, Signatures and Records Management
This form combines & replaces the Request for Mayor’s Signature and Contract Cover Sheet forms.
(Print on pink or cherry colored paper)
Visit Documents.KentWA.gov to obtain copies of all agreementsadccW22373_1_20
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rev. 200821
FOR CITY OF KENT OFFICIAL USE ONLY
(Optional)
* Memo to Mayor must be attached
OK to sign 3/19/2021, TW.
LIFE INSURANCE COMPANY OF NORTH AMERICA
(herein called the Company)
Amendment to be attached to and made a part of the Group Policy
A Contract between the Company and
City of Kent
(herein called the Policyholder)
Policy No.: FLX - 968145
The Company and the Policyholder hereby agree that the Policy is amended as follows:
Effective January 1, 2021, the rates shown on the attached Schedule of Rates will be in force for coverage under the Policy.
No change in rates will be made until 24 months after the effective date of this Amendment. However, the Company
reserves the right to change the rates at any time during a period for which the rates are guaranteed if the conditions
described in the Changes in Premium Rates provision under the Administrative Provisions section of the Policy apply.
Except for the above, this Amendment does not change the Policy in any way.
FOR THE COMPANY
William J. Smith, President
Date: September 21, 2020
Amendment No. 02
TL-004780
Accepted by:
CITY OF KENT
By:___________________________
Dana Ralph, Mayor Date
03/22/2021
SCHEDULE OF RATES
The following monthly rates apply to all Classes of Eligible Persons unless otherwise indicated.
FOR EMPLOYEE BENEFITS
Basic Life Insurance $0.11 per $1,000
FOR SPOUSE AND DEPENDENT CHILD BENEFITS
Basic Life Insurance $1.00 Per Employee
FOR FORMER EMPLOYEE BENEFITS
Monthly Rates are based on units of $1,000.
Under Age 20 $.153 Age 60 - 64 $2.461
Age 20 - 24 $.144 Age 65 - 69 $4.065
Age 25 – 29 $.153 Age 70 - 74 $6.143
Age 30 - 34 $.177 Age 75 - 79 $9.792
Age 35 - 39 $.190 Age 80 - 84 $15.523
Age 40 - 44 $.243 Age 85 - 89 $24.106
Age 45 - 49 $.384 Age 90 - 94 $36.119
Age 50 - 54 $.726 Age 95 and over $51.278
Age 55 - 59 $1.347
A change in rates due to a change in the Former Employee's age will become effective on the Policy Anniversary
coinciding with or following the Former Employee's birthday.
FOR FORMER SPOUSES OR SPOUSES OF FORMER EMPLOYEE BENEFITS
Monthly Rates are based on units of $1,000.
Under Age 20 $.153 Age 60 - 64 $2.461
Age 20 - 24 $.144 Age 65 - 69 $4.065
Age 25 – 29 $.153 Age 70 - 74 $6.143
Age 30 - 34 $.177 Age 75 - 79 $9.792
Age 35 - 39 $.190 Age 80 - 84 $15.523
Age 40 - 44 $.243 Age 85 - 89 $24.106
Age 45 - 49 $.384 Age 90 - 94 $36.119
Age 50 - 54 $.726 Age 95 and over $51.278
Age 55 - 59 $1.347
Spouse rates are based on the spouse's date of birth. A change in rates due to a change in the Spouse's age will become
effective on the Policy Anniversary coinciding with or following the Spouse's birthday.
FOR FORMER DEPENDENT CHILD BENEFITS
Rates are based on $25,000 per Month.
Under Age 20 $2.377 Age 45 - 49 $9.777
Age 20 - 24 $2.777 Age 50 - 54 $16.377
Age 25 - 29 $2.977 Age 55 - 59 $23.477
Age 30 - 34 $3.600 Age 60 - 64 $38.250
Age 35 - 39 $4.177 Age 65 - 69 $54.077
Age 40 - 44 $6.200
Rates are based on $50,000 per Month
Under Age 20 $4.750 Age 45 - 49 $19.550
Age 20 - 24 $5.550 Age 50 - 54 $32.750
Age 25 - 29 $5.950 Age 55 - 59 $46.950
Age 30 - 34 $7.200 Age 60 - 64 $76.500
Age 35 - 39 $8.350 Age 65 - 69 $108.150
Age 40 - 44 $12.400
A change in rates due to a change in the Former Dependent Child's age will become effective on the Policy Anniversary
Date coinciding with or following the Former Dependent Child's birthday.
TL-004718