HomeMy WebLinkAboutHR18-161 - Amendment - CIGNA - Voluntary Group Life Insurance Policy #FLX-968146 - 01/01/2021ApprovalOriginator:Department:
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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 - 968146
PLEASE READ
IMPORTANT: The attached amendment to your policy has been made at your request, and will be effective on the date
shown within the amendment. Please review this amendment immediately and confirm that it accurately reflects your
request and is consistent with your intentions. If amended certificates have been provided, please review these as well. If
there are any errors or discrepancies, please notify your account manager or account service representative immediately. If
you have not notified your account manager or account service representative of any errors or concerns, continued payment
of premium more than 31 days after delivery of this amendment will be deemed acceptance of this amendment.
Accepted by:
CITY OF KENT
By:________________________
Dana Ralph, Mayor Date
03/22/2021
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 - 968146
This Amendment is attached to and made part of the Policy specified above. It is subject to all of the policy provisions that
do not conflict with its provisions.
The Company and the Policyholder hereby agree that the Policy is amended as follows:
1.This Amendment will be in effect on the Effective Date(s) shown below only for insured Employees in Active Service
on that date. If an Employee is not in Active Service on the date his insurance would otherwise become effective, it
will be effective on the date he returns to Active Service.
Effective January 1, 2021, the Annual Enrollment Period under the Schedule of Benefits for Class 1 is deleted in its
entirety and is replaced by the following:
Annual Enrollment Period
For Employees
During an Annual Enrollment Period, an Employee currently insured under the Voluntary Life Insurance portion of
this Policy may increase his or her Voluntary Life Insurance Benefit by five units, as long as the total Benefit does not
exceed the Guaranteed Issue Amount, without satisfying the Insurability Requirement. An Employee who is eligible
for the Voluntary Life Insurance portion of this Policy but who has not previously enrolled may become insured under
the Policy as long as the total Benefit does not exceed the Guaranteed Issue Amount, without satisfying the Insurability
Requirement. Guaranteed Issue Amounts are shown above. Insurance will be effective on the later of the Policy
Anniversary following the Annual Enrollment Period.
An Employee may increase coverage or become insured for a Benefit in excess of amounts described above only if he
or she satisfies the Insurability Requirement. Any excess amounts will be effective on the later of the Policy
Anniversary following the Annual Enrollment Period or the date the Insurance Company agrees in writing to insure the
Employee.
For Spouses
During an Annual Enrollment Period, an eligible Employee may elect coverage for his or her eligible Spouse. If a
Spouse is currently insured under the Voluntary Life Insurance portion of this Policy, his or her Voluntary Life
Insurance Benefit by five units, as long as the total Benefit does not exceed the Guaranteed Issue Amount, without
satisfying the Insurability Requirement. If a Spouse is eligible for the Voluntary Life Insurance portion of this Polic y
but has not previously enrolled, he or she may become insured under the Policy as long as the total Benefit does not
exceed the Guaranteed Issue Amount, without satisfying the Insurability Requirement. Guaranteed Issue Amounts are
shown above. Insurance will be effective on the later of the Policy Anniversary following the Annual Enrollment
Period.
A Spouse may increase coverage or become insured for a Benefit in excess of amounts described above only if he or
she satisfies the Insurability Requirement. Any excess amounts will be effective on the later of the Policy Anniversary
following the Annual Enrollment Period or the date the Insurance Company agrees in writing to insure the Spouse.
A request for a Benefit reduction received during an Annual Enrollment Period will become effective on the later of
the Policy Anniversary following the Annual Enrollment Period.
TL-008025-1
2.Effective January 1, 2021, the rates shown on the attached Schedule of Rates will remain 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 (Revised Date: September 30, 2020)
Amendment No. 01
TL-004780
SCHEDULE OF RATES
The following monthly rates apply to all Classes of Eligible Persons unless otherwise indicated.
FOR EMPLOYEE BENEFITS
Voluntary Life Insurance
Monthly Rates are based on units of $1,000
Under Age 20 $.06 Age 60 - 64 $.73
Age 20 - 24 $.06 Age 65 - 69 $1.40
Age 25 – 29 $.06 Age 70 - 74 $2.50
Age 30 - 34 $.08 Age 75 - 79 $3.70
Age 35 - 39 $.09 Age 80 - 84 $6.61
Age 40 - 44 $.13 Age 85 - 89 $6.61
Age 45 - 49 $.23 Age 90 - 94 $6.61
Age 50 - 54 $.35 Age 95 and over $6.61
Age 55 - 59 $.61
A change in rates due to a change in the Employee's age will become effective on January 1 coinciding with or following
the Employee's birthday.
FOR SPOUSE OR DOMESTIC PARTNER BENEFITS
Voluntary Life Insurance
Monthly Rates are based on units of $1,000.
Under Age 20 $.06 Age 60 - 64 $.73
Age 20 - 24 $.06 Age 65 - 69 $1.40
Age 25 – 29 $.06 Age 70 - 74 $2.50
Age 30 - 34 $.08 Age 75 - 79 $3.70
Age 35 - 39 $.09 Age 80 - 84 $6.61
Age 40 - 44 $.13 Age 85 - 89 $6.61
Age 45 - 49 $.23 Age 90 - 94 $6.61
Age 50 - 54 $.35 Age 95 and over $6.61
Age 55 - 59 $.61
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 January 1 coinciding with or following the Spouse's birthday.
FOR DEPENDENT CHILD BENEFITS
Voluntary Life Insurance $.20 Per $1,000
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 SPOUSE OR DOMESTIC PARTNERS OR SPOUSE OR DOMESTIC PARTNERS 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 Chi ld's age will become effective on the Policy Anniversary
Date coinciding with or following the Former Dependent Child's birthday.
TL-004718