626-Protective Life Insurance Protective
APPLICATION FOR GROUP INSURANCE
The undersigned Applicant hereby applies to Protective Life Insurance Company for a Group Policy or
Policies providing the types of insurance checked beloW:
Employee Life Insurance
Dependent Life Insurance
Accidental Death And Dismemberment Insurance
'Disability Income Insurance
Medical Care Insurance
Dental Care Insurance
Other (Indicate type of insurance and whether Employee-only or Employees and
Dependents.)
$ -0- initial deposit accompanies this Application.
It is requested that the group insurance herein applied for become effective on 10-0]-96
IT IS UNDERSTOOD AND AGREED THAT:
1. the group insurance wilt become effective on the date requested only if this Application is accepted
at the Home Office of Protective Life Insurance Company in Birmingham, Alabama;
2. the conditions of eligibility, the conditions under which insurance for any person begins and ends,
the insurance coverage, benefits, and amounts, the conditions under which the benefits will be
payable, and other terms and conditions will be in accordance with the Poticy(ies) issued and any
amendments, dders, or endorsements thereto; and
3. the Policy(ies) issued and any amendments, dders, or endorsements thereto, together with the copy
of this Application attached to the Policy(ies) and the individual applications, if any, of b~e persons to
be insured, will constitute the entire centFact
Certain coverages may be required to be offered in the state of issue. Such coverages, if any, are listed
on an attached Supplement to Application for Group Insurance. Each coverage checked "fes" is to be
included. Each coverage checked "No" is not to be included.
Signed at City of Sanford , this 14th day of August ,19 96
City of Sanford
,~F(~/~ "~ rate name of Applicant)
Wi]cIiam A. Simmons
Title City Manager
GMtness)
(Licensed Resident Agent P.O. Box 1788, Sanford, F1. 32772-1788
If Required By Law) (Principal address of Applicant)
CONSENT FORM
SUMMARY PLAN DESCRIPTION - COBRA INITIAL NOTICE
Protective Life Insurance Company, as a convenience to the employer, is willing to include certain
information in bookJets containing the cePdficates of insurance issued to employees in order to assist the
employer in complying with the summary plan description (SPD) requirements of the Employee Retirement
Income Secudty Act of 1974 as amended (ERISA), or the "initial notice of centinuatjon of coverage"
requirements of the Consolidated Omnibus Budget Recondliation Act of 1985 as amended (COBRA), or
both. The data required for this purpose is requested below. Complete only blanks marked * for only the
COBRA initial notice, Complete all blanks for the ERISA SPD only or both the COBRA initial notice and
the ERISA SPD.
* Employer Name City of Sanford
* Plan Name City of Sanford, Florida Flexible Benefits Plan
Plan Sponsor Name City of Sanford
Plan SponsorAddress P.O. Box 1788, Sanford, F1. 32772-1788
Plan Sponsor Telephone Number (407) 330-5627
* Plan Administrator Name Timothy J. McCaule~,
* Plan AdministratorAddress P.O. Box 1788, Sanford, FI. 32772-1788
* Plan Administrator Telephone Number (407) 330-4627
Employer Identification Number 59-6000425
Plan NumberAssigned By Plan Sponsor N/A
* Coverage Provided Under Plan Dental
Date Ending Fiscal Plan Year 09-30 -
Claim Review Offidal Personnel Director
Name of Entity who has authority to amend Ran Personnel Director
Please include the following:
ERISA SPD INFORMATION: X Yes No
COBRA INITIAL NOTICE: X Yes No
The employer understands that Protective Ufe Insurance Company does not guarantee that booldets
containing certificates of insurance will satisfy all legal requirements. The employer is cautioned and
encouraged to consult its own legal counsel regarding requirements and compliance with ERISA. If I have
checked "yes" to Cobra Initial Notice, I acknowledge that I understand and agree to my obligations,
responsibilities and other conditions stated on the reverse side of this page.
For:
City of Sanford
By:
W ll~--'f~', Si~mmons
Title: City Manager
REQUEST FOR COBRA
CONTINUATION OF COVERAGE
We understand and agree that:
1. Qualified beneficiaries who experience a qualifying event will be allowed to continue coverage
under the Group Policy, but only if the qualifying event occurs at a time when our group health
plan is required by COBRA to allow the continuation of coverage under such group health plan.
2. It is the responsibility of the qualified beneficiary to remit contributions directly to us. This
contribution will be sent to Protective Life Insurance Company along with the premium for all
other insureds.
3. Continuation of coverage under the Group Policy is subject to satisfaction of all the conditions
of COBRA including any rufes or regulations adopted (requiring interim compliance) proposed
or otherwise promulgated by any federal agency. This includes, but not limited to, our giving
timely initial notice to qualified beneficiaries of their dghts under COBRA and timely notice to all
qualified beneficiaries who experience a qualifying event.
4. Only the minimum coverage required by law will be available under the Group Policy.
5. All coverage continued will be subject to all the terms, conditions. and provisions of the Group
Policy.
6. To be effective, continuation coverage under COBRA must be applied for on an election-form
satisfactory to Protective Life Insurance Company.
7. Any coverage continued under the Group Policy for any qualified beneficiary will end on the
eadiest date provided by COBRA or the Group Policy.
8. All compliance obligations under COBRA are our sole responsibility. Although Protective Life
Insurance Company will assist us in the administration of COBRA contir-~uation for our
employees, Protective Life Insurance Company assumes no responsibility for our compliance
with federal laws or regulations. Accordingly, we will indemnify and hold Protective Life
Insurance Company harmless from and against any penalty or fee which may be assessed by
a court or governmental agency for failure of our group health plan to comply with COBRA.