Loading...
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.