488-Prudential Insurance Co (/uelaJoaS ls!ssV)
fl'~?;fL~"~r*~'~(~ AS 666I'1 ~aqmaldaS
· ' ' , CIPMd ~!6JoeE) '~lu~l),V
O, ueo!lddV ~o amen almodJoO Jo IlnJ)
aI:IOJNVS JO LLIO
,~5
Z,66 L ' I- ~lenue[, a^!ioa~=l 866 ~ ' L
~Z (Z91~SE;)ZL0/. dOS 00 L98 (0880666 t)Zt0Z. dOS 00 L98
-- II u"'nlo3 I munlo3
~ ~ '11 u~un)oO u! pa~s!l ',~ue
~. %u~oj aJeO qlleaH dnm9 6u!puodsa~joo aq~ 'aleO aA!pa~3 sJ! Jose 'saoelda~ I utunloO
u! pals!l Lujo,~ emO qlleaH dno~E) aq/'a~,ea eABoa~ s~. ~o se peJluoO dno,9 aqI ~o ~ed
smJo~ ~! '4ueu~puaujV s!ql ol paqoe~m s! t~olaq I umnloO u! peis!l ~ujo~ a~eO qileaH dnoje aq~
:sMollot se peBueqo
leql eej8~ 'oul 'ueld eJeO qll~eFI leBuepnJd pub ~eploH loe~luoO
:oN peJluoO aJsOdno 9 ol IuaLupuauN
Z/.00'g~g86
Z0066/9~-00-LM-Z6FHV ~ ,,./ ~
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 EmployeFs 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 ."
861 O0
SCP 7012 (1999083O)
ATU99250-0598/99001
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 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 Column II
86100SCP7012(19991102) 86100SCP7012(19990830)
Effective October 1, 1999 Effective October 1, 1998
,,.,.., CITY OF SANFORD
~c/ (Full or Corporate Name of Applicant)
PR
November 8,1999 By (~(Assistan~
86100
AMD 4023 (19991102)
(03846204)
This Copy Is To ,Ss :::~etained F,: ' "rc~:~ Files
VOIEIBI/IV JO ANVdlAIOO BONV~rlSNI 'IVLLNBORBd BILL V9 's)usllV
(JeploH loejluoO Jo euJeN eisJocboO Jo IlnJ)
aEIOJNVS JO LLIO
: ~ ~66 I. ' I. AJenJqe-i eA!loep, e 866 I- ' L JeqoloO eA!loa~e
~ (9-~9t,813) bOO ~ HOS 00SI38 (0~80666 L) L00 i, HOS 00Sg8
II u'"nloO I utunloO
2~h~rv cra g91;'8~-9 :oN iDP-4uoO dnoJ9 ol lueuJpueuJV ,--~
ZZ00-g~E~86
L0066/9 L00- ~-t~ ~-/,6r'l/~'
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
SOH 1001 (19990830)
ThePrudentml
A~se. ociate Group Manager
The Prudential Health Care System
Orlando Group Operations
2301 Luclen Way, Suite 230
MaRland, FL 32751-7086
407-875-6600 Fax: 407-660-0552
May20,1993
Ms. June Strine
Benefits Technician
City of S anford
P.O. Box 1778
Sanford, Florida 32772-1778
RE: Group Contract: 38462 Amendment 38462-3/16/93-01
Dear June:
;Enclosed is an Amendment(s) for ~e 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
Prudential Ordinary Agency 'i
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 Distribution # Shipped
BOOKLET-CERTIFICATES:
Plus; Code 1 All Employees located 240
38462; Ed. 2/93; Doc. #503911 in a Service Area
Program date; October 1, 1992
RIDERS:
BNC 1001 (38462-1) All Employees not located
effective; October 1, 1992 in a Service Area 8
38462~'~16/93-01
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:
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 Column II
These forms with an 83500 prefix: These forms with an 83500 prefix:
SEP 1001 (1-1)(38462) NONE
effective October 1, 1991
SCH 1001 (38462-2) SCH 1001 (38462-1)
effective October 1, 1992 effective October 1, 1991
CITY OF SANFORD
(Full or Corpor e Name of Contract Holder)
Witness~'~ By
/ (Signature and Title)
Atlanta, GA THE PRUDENTIAL INSURANCE COMPANY OF AMERICA
March 16, 1993 By
~ Secretary)
83500
AMD 1001 (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 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.
1. 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, G-3B462;
(b)
(c) Bearing the code "83500 BNC 1001(38462)".
2. 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 Co~t-No. G-38462;
(b) With an Effective Date~f~;':
(c) Bearing the code "83500**B'r~C 1001(38462-1)".
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.
1. 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)".
2. 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 vyho 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 III 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 III 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