HomeMy WebLinkAboutResolution - 6608 - Application For Group Insurance - Pacific Life And Annuity Company - 11_11_1999Resolution No. 6608
Nov. 11, 1999
Item No. 19
RESOLUTION
BE IT RESOLVED BY THE CITY COUNCIL OF THE CITY OF LUBBOCK:
THAT the Mayor of the City of Lubbock BE and is hereby authorized and
directed to execute for and on behalf of the City of Lubbock an Application for Group
Insurance to provide optional critical care group insurance coverage, by and between the
City of Lubbock and Pacific Life and Annuity Company, and related documents. Said
application is attached hereto and incorporated in this resolution as if fully set forth herein
and shall be included in the minutes of the City Council.
Passed by the City Council this llth day of November 999.
WINDY SiYTON, MAYOR
ATTEST: -
Darnell, City Secretary
APPROVED AS TO CONTENT:
Mary Andreos, Managing Director of
Human Resources
APPROVED AS TO FORM:
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William de Haas
Competition and Contracts Manager/Attorney
gsxcdocs/Group Insurance.res
November 02, 1998
1:1'V PACIFIC LIFE &ANNUITY P.O! Boxif2890 Annuity Company
APadflcUfeCompany Newport Beach, CA 92658-9010
Resolution No. 6608
APPLICATION FOR GROUP INSURANCE N em 111
No- 1999
19
NAME OF APPLICANT (FULL LEGAL COMPANY NAME)
CITY OF LUBBOCK TEXAS 1625 13th Street, Lubbock, Texas 79401
ADDRESS OF APPLICANT
On behalf of the Applicant, I hereby apply to Pacific Life & Annuity Company for the following group insurance coverage(s):
I�
For employees only
For dependents
Living Options""' Coverage (Employer -Paid)
❑
Living Options rm Coverage (Voluntary)
Other (specify)
❑
❑
I request that coverage(s) become effective on:
Month
December
Day
118
Year
11999
Please note if Applicant currently has in force, whether insured or self -funded:
1. Other similar coverages (e.g., critical illness/dread disease/cancer only, etc.). O No Yes*
2. Group medical coverage. O No Yes*
*If you answered Yes to #1 or #2 above, please note:
Insurer(s) B.Lue Cross/Blue Shield Coverage(s) Grout) Major Medical
National Traveler's Life lCancer.Dread-Diseasp-_ TrTT
*If the answer to #1 above is Yes, has coverage been terminated? Mo ❑ Yes Last day coverage was in force
*If the answer to #2 above is Yes, do you intend to retain or replace the coverage? O No EXYes If no, please explain:
The Group Insurance applied for in this application shall not become effective until the following conditions have been met:
1. This application (form 25-20992) is approved by Pacific Life & Annuity Company at its Principal Executive Office at 700
Newport Center Drive, Newport Beach, CA 92660-6397;
2. -ftClflc dfLs--&Al yhas;mslpe and,
3. For voluntary coverage, the required number of eligible employees have agreed to make the required contribution to apply
toward the premium for this insurance. Bi—weekly in arrears,
• Premium payments are payable rwmth#y*rad and are due on the first day of each month after the effective date of this
insurance. • No agent has power on behalf of Pacific Life & Annuity to make or modify any application for insurance, to make any
promise or representation, or to waive any of the Company's rights or requirements. • The above statements are true and
complete to the best of my knowledge and belief. • I understand and agree that such statements and answers shall become a
part of any policy or policies which may ultimately be issued by Pacific Life & Annuity, and are made to induce Pacific Life &.
Annuity to issue the insurance as applied for in this application.
Please note that any person who knowingly, and with intent to injure, defraud, or deceive any insurance company or other person,
files a statement of claim or an application containing materially false, incomplete, or misleading information, may be guilty of a
felony and subject to criminal and civil penalties. (See reverse for state -specific fraud warnings.)
Signature of company officer or other person authorized to purchase insurance
Title
Signat re of writing agent / agent license no.
Signature of authorized Pacific Life & Annuity
repre tative
0 3
Signed at (city and state)
Uay I 10onth / Year
,C a 66oGk -;5 Cr s
X--------- CUT HERE --------- X------------------------------------------------------------ X --------- CUT HERE ---------- X
RECEIPT FOR ADVANCE AYMENT
Received from I Sum of
This sum is receiA
va payment toward the first premium or premiu s for gro insurance for which application has
been made on thac Life & Annuity Company. If Pacific Life & Annuity tiff the Applicant in writing of the
acceptance of tho , su insurance shall be effective from the date agreed n and specified in such notice, with
premiums for it ble from ch effective date, and the amount for which re ipt i ereby acknowledged shall be applied
towards the paymh premium No insurance is rovided in return for thi remium a osit. Insurance shall be provided
on the effective dted above onl ' the event that this application is ap oved as subted. If Pacific Life & Annuity
does not accept ttion, this premiu deposit will be refunded.
Date / Writing
THIS RECEIPT ASSUMES THAT THE CHECK, DRAFT OR`QTHER
THE PAYMENT OF MONEY IS GOOD AND COLLECTABLE.
25-20992-01 (04199
STATE -SPECIFIC REQUIRED FRAUD WARNINGS
Colorado: It is unlawful to knowingly provide false, incomplete, or misleading facts or information
to an insurance company for the purpose of defrauding or attempting to defraud the company.
Penalties may include imprisonment, fines, denial of insurance, and civil damages. Any insurance
company or agent of an insurance company who knowingly provides false, incomplete, or
misleading facts or information to a policyholder or claimant for the purpose of defrauding or
attempting to defraud the policyholder or claimant with regard to a settlement or award payable
from insurance proceeds shall be reported to the Colorado Division of Insurance within the
Department of Regulatory Agencies.
Florida: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files
a statement of claim or an application containing any false, incomplete, or misleading information
is guilty of a felony in the third degree.
Kentucky: Any person who knowingly and with intent to defraud any insurance company or other
person files an application for insurance containing any materially false information or conceal for
the purpose of misleading, information concerning any fact material thereto commits a fraudulent
insurance act, which is a crime.
New Jersey: Any person who includes any false or misleading information on an application for
an insurance policy is subject to criminal and civil penalties.
Ohio: Any person who, with intent to defraud or knowing that he is facilitating a fraud against an
insurer, submits an application or files a claim containing a false or deceptive statement is guilty of
insurance fraud.
Pennsylvania: Any person who knowingly and with intent to defraud any insurance company or
other person files an application for insurance or statement of claim containing any materially false
information or conceals for the purpose of misleading, information concerning any fact material
thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal
and civil penalties.
CITY OF LUBBOCK: APPROVED AS TO CONTENT:
ATTEST:
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Mary Anglews,
Managing Director of Human Resources
APPROVED AS TO FORM:
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William de Haas,
Competition and Contracts Manager
25-20992-01 (04/99