488-Prudential Group Health Pla' ThePrudentm!(
.. c~f =, c...i~d
As~.~ciate Group Manager
The Prudential Health Care System
Odando Group Operations
2301 Lucien Way, Suite 230
Maltland, FL 32751-7086
407-875-6600 Fax: 407-660-0552
May 20, 1993
Ms. lune Stfine
Benefits Technician
City of Sanford
P.O. Box 1778
Sanford, Florida 32772-1778
RE: Group Contract: 38462 Amendment38462-3/16/93-01
Dear June:
Enclosed is an Amendment(s) for the plan of benefits which became effective October 1, 1992.
Please have the Amendment(s) signed by an officer of the company, witnessed and returned to
Karen Bratsch at the above address. There are duplicate copies which you should file with your
contract.
As always, please do not hesitate to contact me with questions.
Sincerely,
R. Cartwright Carmichael
Associate Group Manager
RCC:klb
CO:
Eugene Gizzi
Prudential Ordinary Agency
NOTICE TO CItY OF SANFORD
The following is an invoice of the material that was shipped to you. Any
discrepancies or questions should be directed to-your Prudential Group
Representative.
Invoice of Shipped Material:
Code
BOOKLET-CERTIFICATES:
Plus; Code 1
38462; Ed. 2/93; Doc. #503911
Program date; October 1, 1992
RIDERS:
BNC 1001 (38462-1)
effective; October 1, 1992
Distribution
All Employees located
in a Service Area
All Employees not located
in a Service Area
# Shipped
240
8
Important Notice Regarding Your New
Contract or Contract Amendment
The application for the group contract or the amendment forms attached to this notice should be
signed promptly by an officer of your company and Prudential's copy returned as soon as
possible. Reasons for taking prompt action are described below.
A. ERISA
Most group contract holders having United States employees are subject to the obligations
imposed on them by the Employee Retirement Income Security Act of 1974 (ERISA). Plans which
are subject to ERISA must comply with certain reporting and disclosure requirements. These
requirements include the following:
Plan Documents
All plan documents, including insurance contracts, must be available for examination by plan
participants.
ERISA requires that every plan subject to the Act be in writing and accurately reflect all benefits
under the Plan.
A plan participant must receive a Summary Plan Description within 90 days of becoming a
participant or within 120 days after the date the plan js established. The Summary Plan
Description must be up-to-date and reflect all the benefits of the plan as it existed not more than
120 days prior to the date they enter the plan.
Thereafter. if there have been plan changes a supplement or new Summary Plan Description must
be distributed within 210 days after the end of the fifth plan year following the end of the pedod
covered by the last distributed Summary Plan Description (or, if there have not been any plan
changes, within 210 days after the end of the tenth plan year following the end of the period
covered by the last distributed Summary Plan Description).
Notice of Plan Changes
Plan participants must receive written notice of certain plan changes within .seven months after
the end of the plan year in which such change is adopted. The Secretary of Labor must be
notified of those changes within the same time period if you have filed a copy of your Summary
Plan Description with the Department of Labor. The items which must be reported, when
changed, are those which appear in the Summary Plan Description.
Since these documents either rely o~ the group contract for the description of the benefits or
incorporate the group contract into them by reference, it is important to keep your group contract
and booklets as complete and up-to-date as aossible.
B. LITIGATION
As you are aware," there has been an increasing tendency to resort to litigation to resolve disputes.
In the event of litigation involving your benefit plan, your counsel should have a copy of the
contract on a current basis in order to assist counsel in making decisions.
If you have any questions or would like further information, please do not hesitate to contact your
GID 222 Ed. 9-91 A
Amendment
(
To Group Contract No:
38462 .'~' ~16/93-01
G-38462
By their signatures below, the Contract Holder and Prudential agree that the Group Contract is
changed as follows:
Each insurance form listed in Column I below is attached to this Amendment; it forms part
of the Group Contract as of its Effective Date. Each insurance form listed in Column I
replaces, as of its Effective Date, the corresponding insurance form(s), if any, listed in
Column II.
Column I
These forms with an 83500 prefix:
SEP 1001 (1-1)(38462)
effective October 1, 1991
SCH 1001 (38462-2)
effective October 1, 1992
Column II
These forms with an 83500 prefix:
NONE
SCH 1001 (38462-1)
effective October 1, 1991
Witness
Atlanta, GA
March 16, 1993
83500
AMD 1001
By
CITY OF SANFORD
(Full or Corpor e Name of Contract Holder)
Z (Signature and Title)
THE PRUDENTIAL INSURANCE COMPANY OF AMERICA
By
t ;sis ant Secretary)
(38462)A
Separate
(
Experience
This applies when Prudential determines the share, if any, of its divisible surplus allocable to
the Group Contract. In doing that, Prudential will treat separately the financial experience of:
These Coverages:
(1) Major Medical Expense Coverage.
(2) All other Coverages of the Group Contract.
83500
SEP 1001 (1-1)(38462)A
Schedule
Plans
Effective Date: October 1, 1992
Group Contract: No.: G-38462
This Schedule of Plans sets forth the Plan of Benefits that applies to each Covered Class under
the Group Contract listed below as of the Effective Date. The Plan of Benefits for a Covered
Class is determined by: (1) the Group Insurance Certificates that apply to the Covered Class;
and (2) any modification to those Certificates, provided the modification is listed below or
included in an amendment to the Group Contract. A copy of each Certificate and any
modification to it are attached to the Group Contract and made a part of it.
Covered Class:
All Employees included in the Covered Classes of the Group Insurance Certificate
described below.
Plan of Benefits that Applies to this Covered Class:
The Coverage(s) described in the Group Insurance Certificate:
(a) Prepared for Group Contract No. G-38462;
(b) With the Program Date of October 1, 1990;
(c) Bearing the code "LIFE" and "38462; Ed. 1/91; Doc. #500875" and;
The modifications to the Certificate described in the Notice To Employees:
(b) i
(c) Bearing the code "83500 BNC 1001 (38462)".
Covered Class:
All Employees included in the Covered Classes of the Group Insurance Certificate
described below.
Plan of Benefits that Applies to this Covered Class:
The Coverage(s) described in the Group Insurance Certificate:
(a) Prepared for Group Contract No. G-38462;
(b) With the Program Date of October 1, 1992;
(c) Bearing the code "Plus; Code 1" and "38462; Ed. 2/93; Doc. #503911" and;
The modifications to the Certificate described in the Notice To Employees:
(a) Prepared for Group Cont,,,q~,t:,No. G-38462;
(b) With an Effective Date ~Sf; ..,.
(c) Bearing the code "83500'B'~C 1001 (38462-t)".
83500
SCH 1001 (38462 2)A
Schedule of
Plans
Effective Date: October 1, 1992
Group Contract No.: G-38462
This Schedule of Plans sets forth the Plan of Benefits that applies to each Covered Class under
the Group Contract listed below as of the Effective Date. The Plan of Benefits for a Covered
Class is determined by: (1) the Group Insurance Certificates that apply to the Covered Class;
and (2) any modification to those Certificates, provided the modification is listed below or
included in an amendment to the Group Contract. A copy of each Certificate and any
modification to it are attached to the Group Contract and made a part of it.
Covered Class:
All Employees included in the Covered Classes of the Group Insurance Certificate
described below.
Plan of Benefits that Applies to this Covered Class:
The Coverage(s) described in the Group Insurance Certificate:
(a) Prepared for Group Contract No. G-38462;
(b) With the Program Date of October 1, 1990;
(c) Bearing the code "LIFE" and "38462; Ed. 1/91; Doc. #500875" and;
The modifications to the Certificate described in the Notice To Employees:
(a) Prepared for Group Contract No. G-38462;
(b) With an Effective Date of October 1, 1990;
(c) Bearing the code "83500 BNC 1001(38462)".
Covered Class:
All Employees included in the Covered Classes of the Group Insurance Certificate
described below.
Plan of Benefits that Applies to this Covered Class:
The Coverage(s) described in the Group Insurance Certificate:
(a) Prepared for Group Contract No. G-38462;
(b) With the Program Date of October 1, 1992;
(c) Bearing the code "Plus; Code 1" and "38462; Ed. 2/93; Doc. #503911" and;
The modifications to the Certificate described in the Notice To Employees:
(a) Prepared for Group Contract No. G-38462;
(b) With an Effective Date of October 1, 1992;
(c) Bearing the code "83500 BNC 1001(38462-1)".
83500
SCH 1001 (38462-2)A
RIDER TO BE ATTACHED TO YOUR BOOKLET-CERTIFICATE coded ."Plus"
NOTICE OF CHANGE
Covered Classes: The "Covered Classes" are these Employees of the Contract Holder (and its
Associated Companies):AII Employees w. ho are not located in a Service Area.
Effective Date of Change: The first day on or after October 1, 1992, on which you are insured.
(See the When You Become Insured section.) The Delay of Effective Date section of your
Booklet-Certificate applies to this change.
Group Contract No. G-38462
THIS CERTIFIES that the following changes are made in your Booklet-Certificate:
1. The section "Benefits" appearing in the Schedule of Benefits is replaced by this:
BENEFITS
for Eligible Charges are subject to the Limits under Part Ill and the Overall Benefit Maximum(s).
Amount Payable: The Covered Percent that applies to the Eligible Charges.
Covered Percent: The following Covered Percent applies to the Eligible Charges, except
where any differences are described in the Coverage for charges for certain services for
mental, psychoneurotic and personality disorders, alcoholism and drug dependency: For
each person in each Calendar Year, the Covered Percent is: 80%, except it is 100% after
the 80% and any lesser percent used to determine benefits apply to a total of $10,000
Eligible Charges incurred for the person's Sicknesses and Injuries in that Calendar Year.
Charges used to meet a Deductible and charges already payable at 100% do not count
toward that $10,000.
2. The percentage used,to determine the benefit amount payable under subsection (2)(c)(i) of
Section A under Part Ill of the Major Medical Expense Coverage form is 80% and not any
lesser percentages shown in the Coverage.
THE PRUDENTIAL INSURANCE COMPANY OF AMERICA
83500
BNC 1001 (38462-1)A