The URL can be used to link to this page

Home My WebLink AboutResolution - 6609 - Application For Vision Care Benefits - Fidelity Security Life Insurance Company - 11/11/1999Resolution No. 6609 Nov. 11, 1999 Item No. 20 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 vision care benefits, by and between the City of Lubbock and Fidelity Security Life Insurance 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 11th day of November , 19 9. ..e - WINDY SI ON, MAYOR ATTEST: . Kaythi4 Darnell, City Secretary AS TO CONTENT: Mary Andr6ks, Managing Director of Human Resources APPROVED AS TO FORM: William de Haas Competition and Contracts Manager/Attorney gsxcdocsNision Care Benefits.res November 02, 1998 FIDELITY SECURITY LIFE INSURANCE COMPANY Kansas City, Missouri PLOYER INFORMATION Resolution No. 6609 Nov. ll, 1999 Employer Name: City of Lubbock Tax ID # 756000590 DBA Name (if other than above): N/A Business Address: P.O. Box 2000 City Lubbock State TX Zip 79457 Mailing Address (if other than above): 162513' Street City Lubbock State TX Zip 79401 Correspondent: Lou L Moore Title Benefits Coordinator Phone Numbers 806 ) 775-2317 Fax Number( 806 ) 775-3316 Type of Business: Q Proprietorship ❑ Corporation ❑ Partnership 0 Other (Specify) Municipality If any subsidiary or affiliated companies are to be insured or any Employees are working at a location other than the address above, please explain: Will this plan replace any existing coverage? ❑ Yes 0 No If "Yes", indicate name and address of existing insurer: Name: Address: City State Zip If "Yes", are any Employees on COBRA continuation? ❑ Yes ❑ No How many? Effective date of existing coverage Termination date of existing coverage (if applicable) Number of Full-time Employees - 1780 - Number Applying PROBATIONARY PERIOD For New Employees: ❑ 30 days ❑ 60 days ❑ 90 days ❑ 180 days 0 Other: Actively at work for one full pay period Probationary Period is waived for present Employees 0 Yes ❑ No Number of Employees who have not yet completed the probationary period II. PLAN SELECTION Benefit Package Selected 1. Vision Examination: $_10_Copay. $_30_ maximum benefit payable by Company. 2. Vision Materials: $ 20_Copay. $_105 maximum benefit payable by Company. 3. Benefit Period: Eye Exam O 12 months Materials 0 24 months III. EVIDENCE OF INSURABILITY Evidence of Insurability is not required for each Employee. IV. PREMIUMS Contribution towards premium? ❑ Yes 0 No Employer's Premium Contribution for: Employees:—O—% Dependents:—O—% Are Employee and Dependent premiums being paid through a Section 125 Plan? OYes ❑ No IV.-PREMIl1MS (Continued) Are Employee and Dependent premiums being collected by payroll deductionOYes ❑ No Premium received with application:_$0_ Number of Participants Employees without dependents Employees with dependents (Note: Please attach a list of all participants to this application. This list may be a hard copy, diskette or computer tape.) Premiums shall be payable in advance at the rates set forth in the following Schedule of Premiums. V. SCHEDULE OF PREMIUMS (see attached rate sheet) $8.54 Employee $17.09 Employee + Spouse $16.20 Employee + Children $22.16 Family V. ELIGIBILITY Choose One: ELIGIBLE CLASS B The Employees eligible for insurance under the Policy shall be all the Full-time Employees of the above named Employer, and each Employee's Dependents. If both husband and wife are Employees, either the husband or wife, but not both, may elect coverage for their Dependents. Eligible Dependents may be added to the Policy on any premium due date. As used here, Full-time Employee means an Employee who is performing all the usual duties of his or her position at the Employer's usual place of business at least 30 or more hours per week. A Part-time Employee is an Employee who does not meet this definition. Dependents may not be included as Eligible Persons unless the Dependent's parent or spouse is covered under the Policy. ❑ The Employees eligible for insurance under the Policy shall be all the Employees of the above named Employer, and each Employee's Dependents. If both husband and wife are Employees, either the husband or wife, but not both, may elect coverage for their Dependents. Eligible Dependents may be added to the Policy on any premium due date. ❑ The Employees eligible for insurance under the Policy shall be DATE ELIGIBLE 1. Each Employee included in an Eligible Class on the Policyholder's Effective Date will be eligible on that date, provided the Employee has completed any required probationary period shown below. 2. Each Employee included in an Eligible Class on the Policyholder's Effective Date, and who had partially satisfied the required probationary period prior to the Policyholder's Effective Date, will be eligible on the first day of the calendar month coinciding with or next following the date of completion of the probationary period. 3. Each Employee who enters an Eligible Class AFTER the Policyholder's Effective Date will be eligible on the first day of the calendar month coinciding with or next following: a. completion of any required probationary period; or b. the Employee's date of employment, if a probationary period is not required. EMPLOYEE ENROLLMENT 1. .Each Employee may request coverage for him or herself and eligible Dependents. 2. The Company reserves the right, based upon Our underwriting procedures, to require that the eligible Employee and/or Dependent of a Policyholder submit an enrollment form and agree to pay any premium contribution, if required, before coverage will become effective for the Employee and/or Dependent. DELAYED ENROLLMENT Each Employee who waives or declines insurance when he or she becomes eligible will not be eligible again until the next open enrollment for the plan. If insurance is waived or declined for eligible Dependents, then those Dependents will not become eligible again until the next open enrollment for the plan. PARTICIPATION REQUIREMENT The Policyholder is required to maintain the minimum participation requirements of the Company as follows: If part of the premium is derived from funds contributed by the insured Employees, at least 30% of the eligible Employees must elect to make the required contribution, and at least 10 Employees must be covered on the Policy's Effective Date. When a contribution is not required by the Employee, then 100% of the eligible Employees must be covered at all times. VII. EFFECTIVE DATE It is desired that the policy shall become effective at 12:01 A.M. Standard Time at the Employers address herein, on the _1st day of _December—, _1999_, provided this application shall have been accepted by the Company. The Policy, if issued, shall be effective for a term of one year from the effective date and maybe extended for two (2) additional one (1) year terms at the agreement of both parties. The Employer hereby makes application to Fidelity Security Life Insurance Company for Vision Care Benefits. The Employer agrees to maintain and furnish any records necessary to administer the plan, and to pay premiums monthly in advance. The Employer certifies that all the information shown on this application and any attachments are correct and complete and understands that the Insurance Company intends to rely on this information in determining whether or not the enrolling Employees may become insured. It is further understood and agreed that NO INSURANCE WILL BECOME EFFECTIVE UNTIL APPROVED BY THE INSURANCE COMPANY; and that no field representative of the Insurance Company has the authority to modify any conditions of application or policies by making any promise or representation. It is understood that the insurance as to any Employee will NOT become effective on the date insurance should otherwise become effective if he is not at work', on such date performing all duties of his occupation and otherwise meets the requirements of the Insurance Company. Dated at: Lubbock, TX this 11th f Novj6pber , 19 99 eoir Signed for the Employer. Windy Sitton Title: Ma WRITING AGENTS CERTIFYING STATEMENT I ceri;ify that I have accurately recorded on this application the information supplied by the proposed policyholder(s). Agent Name (print): Wayne Pierce Agent No. Address Broker Signature X e iy m )mace `;ry1- City Phone # State Zip Fax # Attes Kaythie D 1, City Secretary Approved as to to t: r Mary AndrewW Managing Director of Human Resources Ap roved as to form: William de Haas, Competition & Contracts Manager p r v :daas t Conten & Fo Chris a ide, Vice President Select Networks