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HomeMy WebLinkAbout92-0226 WASHINGTON NATIONAL INSURANCE RESOLUTION AUTHORIZING EXECUTION OF AN AGREEMENT WITH WASHINGTON NATIONAL INSURANCE COMPANY BE IT RESOLVED BY THE CITY COUNCIL OF THE CITY OF ELGIN, ILLINOIS, that Larry L. Rice, City Manager, and Dolonna Mecum, City Clerk, be and are hereby authorized and directed to execute an agreement on behalf of the City of Elgin with Washington National Insurance Company for an employee insurance program, a copy of which is attached hereto and made a part hereof by reference. s/ George VanDeVoorde George VanDeVoorde, Mayor Presented: February 26, 1992 Adopted: February 26, 1992 Omnibus Vote: Yeas 7 Nays 0 Recorded: Attest: s/ Dolonna Mecum Dolonna Mecum, City Clerk wasrlington INSURANCE COMPANY 1630 CHICAGO AVENUE •EVANSTON,ILLINOIS 60201 SUPPLEMENT TO MASTER APPLICATION FOR GROUP INSURANCE made to WASHINGTON NATIONAL INSURANCE COMPANY, EVANSTON, ILLINOIS 60201 To: WASHINGTON NATIONAL GROUP OFFICE Three Continental Towers, Suite 606, 1701 Golf Road Rolling Meadows, IL 60008 Attention: Sandra L. Groeneveld Full Legal Name of Policyholder: City of Elgin Amend Group Plan Number: #62945 Requested Effective Date: March 1 , 1992 • On behalf of the Policyholder I request that the Company amend the Policy for the plan shown above as follows: 1. Change the Waiting Period from: Date following 30 days of employment to: 1st of the month following date of employment 2. Change Mandatory Second Surgical Opinion benefit to a Voluntary Second Surgical Opinion benefit by deleting the listing of procedures requiring a Second Surgical Opinion and the 50% penalty of all charges for any surgical procedure on that listing when a Second Surgical Opinion was not obtained. CD F15767-1 (over) (491} • I acknowledge that certain optional coverages have been offered to the Policyholder as required by state statutes and I have either accepted or declined these on behalf of the Policyholder as follows: accept decline Mental/Psychiatric Disorders o This optional benefit pays the insured percentage of charges for inpatient treatment (including outpatient convulsive therapy) and 50% of charges for outpatient treatment of mental/psychiatric disorders. There are no internal limits, but this benefit will be limited to the lesser of $10,000 or 25% of the maximum benefit payable while the insured is covered under the policy in each benefit period. PLEASE NOTE: Washington National's standard benefit also pays the insured percentage of charges for inpatient therapy (including outpatient convulsive therapy) and 50% of charges for out-patient treatment of mental/psychiatric disorders. However, the standard benefit is limited to a maximum of $25 per outpatient visit and 52 visits per calendar year. The standard calendar year benefit is $25,000. A change in medical benefits or benefit amounts takes effect on the date of the change except that benefits will not change (1) for an Insured Person not actively at work or (2) for an Insured Dependent hospital confined. Increases in Life Benefits (including Dependent Life) and AD&D Benefits are effective on the date of change only if the Insured Person is actively at work. Decreases in Life Benefits (including Dependents' Life) and in some cases AD&D Benefits are effective whether or not the Insured Person is actively at work. Any changes required by State Regulations shall also be incorporated on the required dates. I understand that the actual terms and conditions of coverage are those contained in the amended Policy into which this Supplemental Application will become a part. I also understand that the amended Policy will not become effective'- -nd until the Company accepts this Supplemental Application. Upon acceptance the Compan will i e the neces - amendments to the Policy to the Policyholder. Eim AO X. ,1_ 2diuce . 2 7 /F72-, SI U. OF AU HORIZED PURCHASER DATE TITLE / ay WITNESS Y 11,x- Erb ck„ SIGNATUR OF SALES REPRESENTATIVE/ LICENSED RESIDENT AGENT GROUP OFFICE APPROVED DATE UNDERWRITER Sa©NATuRE. • RVP:!NIT::;: :::::::::::::::::::::::::::::::::: F15767-1 IL (4-91)