488-Prudential Group-Amendment ATL/97141-0016/99002
98223-0077
C, oN~,-tt-{
Amondm nt To Group Health Care Contract No:
GY-38462-FL
By their signatures below, the Contract Holder and Prudential Health Care Plan, Inc. agree that
the Group Health Care Contract is changed as follows:
The Group Health Care form listed in Column I below is attached to this Amendment; it forms
part of the Group Contract as of its Effective Date. The Group Health Care form listed in
Column I replaces, as of its Effective Date, the corresponding Group Health Care form, if
any, listed in Column II.
Column I
86100 SCP 7012(19990830)
Effective October 1, 1998
Column II
86100 SCP 7012(38462)
Effective January 1, 1997
Witne~'/'~~--"'~'
Atlanta, Georgia
CITY OF SANFORD
(Full or Corporate Name of Applicant)
By jD~~,.i~i~
PRUD (Signa CARE PLAN, INC.
September 1.1999
By
86100
AMD 4O23
'This Colpy ~s To Be ae¢a~r~ ~ For x.:c~r .,
(19990830)
(03846203)
Schedule Of Plans
Effective Date: October 1, 1998
Group Contract No: GY-38462-FL
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 Certificates of Group Health Care Coverage (or other evidence of coverage) that apply to the
Covered Class, and (2) any modification to those Certificates, provided the modification is included in an
amendment to the Group Contract. A copy of each Certificate (or other evidence of coverage) and any
modification to it is attached to the Group Contract and made a part of it.
1. Covered Class:
All Employees of the Contract Holder who permanently reside in the Service Area and are eligible but
not covered under the Employer's Health Benefits Plan.
Plan of Benefits that Applies to this Covered Class:
The benefits described in the Certificate of Group Health Care Coverage (or other evidence of
coverage):
(a) Prepared for Group Contract No. GY-38462-FL.
(b) Bearing the code "38462; Ed. 19990830; Doc. #03846200."
2. Covered Class:
All Employees of the Contract Holder who permanently reside in the Service Area and are eligible but
not covered under the Employer's Health Benefits Plan.
Plan of Benefits that Applies to this Covered Class:
The benefits described in the Certificate of Group Health Care Coverage (or other evidence of
coverage):
(a) Prepared for Group Contract No. GY-38462-FL.
(b) Bearing the code "38462; Ed. 19990830; Doc. #03846201 ."
86100
SCP 7012 (19990830)
ATL/97141-0016/99001
98223-0077
Amendment To Group Contract No: G-38462
By their signatures below, the Contract Holder and Prudential agree that the Group Contract is
changed as follows:
The insurance form listed in Column I below is attached to this Amendment; it forms part of the
Group Contract as of its Effective Date. The insurance form listed in Column I replaces, as of its
Effective Date, the corresponding insurance form, if any, listed in Column II.
Column I
83500 SCH 1001 (19990830)
effective October 1, 1998
By
Column II
83500 SCH 1001 (38462-5)
effective February 1, 1995
CITY OF SANFORD
(Full or Corporate Name of Contract Holder)
' L,J I
Atlanta, GA
THE PRUDENTIAL INSURANCE COMPANY OF AMERICA
September 1,1999
By
83500
AMD 1001
This Copy Is To Be Reta!.~ed For Yoer Files
(19990830)
(03846202)
Schedule of Plans
Effective Date: October 1, 1998
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, 1998;
(c) Bearing the codes "38462; Ed. 19990830; Doc. #0TOE0005"
83500
SCH 1001 (19990830)
AT1_/99250-0598/99001
Amendment To Group Health Care Contract No:
GY-38462-FL
By their signatures below, the Contract Holder and Prudential Health Care Plan, Inc. agree that the
Group Health Care Contract is changed as follows:
The Group Health Cam form listed in Column I below is attached to this Amendment; it forms
part of the Group Contract as of its Effective Date. The Group Health Care form listed in Column
I replaces, as of its Effective Date, the corresponding Group Health Care form, if any, listed in
Column II.
Column I
86100 SCP 7012(199911 02)
Effective October 1, 1999
Column II
86100 SCP 7012(19990830)
Effective October 1, 1998
CITY OF SANFORD
(Full or Corporate Name of Applicant)
By ~
November 8,1999
By
86100
AMD 4O23
'This Copy Is To Ss F:%~,-atained Fc," Yc;,,,;F Files
(19991102)
(03846204)
Schedule Of Plans
Effective Date: October 1,1999 '~.
Group Contract No: GY-38462-FL
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 Certificates of Group Health Care Coverage (or other evidence of coverage)
that apply to the Covered Class, and (2) any modification to those Certificates, provided the
modification is included in an amendment to the Group Contract. A copy of each Certificate (or other
evidence of coverage) and any modification to it is attached to the Group Contract and made a part
of it.
Covered Class:
All Employees of the Contract Holder who permanently reside in the Service Area and are
eligible but not covered under the Employer's Health Benefits Plan.
Plan of Benefits that Applies to this Covered Class:
The benefits described in the Certificate of Group Health Care Coverage (or other evidence of
coverage):
(a) Prepared for Group Contract No. GY-38462-FL.
(b) Bearing the code "38462; Ed. 19990830; Doc. #03846200."
86100
SCP 7012 (19991102)