99-28 Resolution No. 99-28
RESOLUTION
AUTHORIZING EXECUTION OF AN AGREEMENT WITH
MUTUAL OF OMAHA COMPANIES
BE IT RESOLVED BY THE CITY COUNCIL OF THE CITY OF ELGIN,
ILLINOIS, that Joyce A. Parker, City Manager, be and is hereby
authorized and directed to execute an agreement on behalf of
the City of Elgin with Mutual of Omaha Companies for an
employee health insurance program, a copy of which is attached
hereto and made a part hereof by reference.
s/ Robert Gilliam
Robert Gilliam, Mayor Pro Tem
Presented: January 27, 1999
Adopted: January 27 , 1999
Vote: Yeas 5 Nays 0
Attest:
s/ Dolonna Mecum
Dolonna Mecum, City Clerk
APPLICATION TO
'MUTUAL OF OMAHA INSURANCE COMPANY/UNITED OF OMAHA LIFE INSURANCE COMPANY
FOR GROUP COVERAGE
1. UNDERWRITING COMPANY (Check Appropriate Box Below):
MUTUAL OF OMAHA INSURANCE COMPANY For Home Office Use Only
❑ UNITED OF OMAHA LIFE INSURANCE COMPANY
POLICY NUMBER(S) ASSIGNED
located at Mutual of Omaha Plaza, Omaha, NE 68175
2. APPLICANT (Full Legal Name) C I of£ )°)i
STREET ADDRESS 150 0 be )C -te r (O bcrt
' �g
CITY iYl STATE , noiS ZIP CODE (,- Ci � d
TELEPHONE NUMBER ( V1 7 ) 93\ - GOO
3. CONTINUATION OF COVERAGE INFORMATION 5-e c' � &A
List below the requested detail, for ALL employees or dependents whose Plan coverage is to be continued under the
Consolidated Omnibus Reconciliation Act of 1985 (COBRA) or under any State mandated or any other continuation
of benefits if Plan Payments on behalf of these individuals are to be considered for reimbursement under the
policy(ies).
Check mark applicable boxes below.
Name of Individual Original
Social Security No. Starting Date of
Continued Coverage Termination Death Divorce Other (If Other, please explain)
■
❑ ❑ ❑ ❑
❑ ❑ ❑ ❑
❑ ❑ ❑ ❑
❑ ❑ ❑ ❑
(Photo this page for additional Names and Information)
Form 10634GA-MU-EZ STOP-LOSS
4.• THE FOLLOWING IS UNDERSTOOD AND AGREED UPON (UNLESS SPECIFIED IN 5 BELOW.)
(a) Plan Payments on behalf of an eligible employee who is working for the applicant for pay for 30 hours or more
a week at his or her regular job and customary place of employment will be considered for reimbursement as
described in the policy(ies).
(b) Flan Payments on behalf of an eligible retiree or dependent who is:
1. not hospital confined;
2. not confined in any institution or facility other than a hospital or at home or elsewhere due to an injury or
sickness; and
3. not disabled, either physically or mentally, to the extent of being unable to perform all of the usual and
customary duties and activities of a person of the same age and sex who is in good health;
will be considered for reimbursement as described in the policy(ies).
(c) Other coverage requirements are as described in the policy(ies).
5. Coverage is applied for as specified in the proposal dated with the following modifications;
A/� J► I 1 1 )� rck;: L S
� J A.L7 Ve / c�� WO f K. (-nd, /`1 G 4 f L'� G.4 L. i� t/I ctel\f }d PnTS pi;it s!CaS
ree
E Itc;; emp10yee 5 �epe en4-s 3 I b<; L?af tie c1
(Ape IN c �5ja,3Le of c�1.k \(how `ed5,
If no modifications are shown above, none will be presumed.
6. FINANCIAL CONDITION
Within the last 5 years, has the applicant remained continually solvent? R2 Yes ❑ No
Does the applicant reasonably expect to be solvent within the next 12 months? Yes ❑ No
If no to either question, please give details.
Solvent means not having filed a voluntary or involuntary petition in bankruptcy, a reorganization or an arrangement
with creditors, or a general assignment for the benefit of creditors, the ability to pay debts as they become due, not
having a trustee, receiver or other custodian appointed on its behalf, or any other case or proceeding under any
bankruptcy or solvency law, or the commencement of any dissolution or liquidation proceeding.
Requested effective date of the policy(ies): 3 }
Ste.
This application is submitted with the following advance payment: $ f_G`1
Form 10634GA-MU-EZ STOP-LOSS
I understand that the insurer will rely and act upon the answers, statements and any misstatements or omissions of
information that are made on this Application or given and used in the preparation of the Proposal upon which this
application is based. Erroneous information and any material omission of information can result in the rescission,
cancellation or rerating of coverage issued in reliance thereon.
If this application is not approved by an officer at the Home Office of Underwriting Company, no coverage is in effect at any
time and any advance payment received will be returned.
If this application is approved by an officer at the Home Office of the Underwriting Company, it will be attached to and made
a part of the policy and any reissue of the policy which is approved by an officer at the Home Office of the Underwriting
Company. Unless notified in writing of an effective date other than the requested effective date shown above, the effective
date of the policy will be as shown above.
Receipt of the policy or any reissued policy, and payment of any subsequent premium for the policy or any reissued policy,
will constitute the applicant's acceptance of the provisions of the policy or the reissued policy.
For Applicant:
By
(Signature and Title)
Date —
Form 10634GA-MU-EZ STOP-LOSS
APPLICATION TO
'MUTUAL OF OMAHA INSURANCE COMPANY/UNITED OF OMAHA LIFE INSURANCE COMPANY
FOR GROUP INSURANCE
1. UNDERWRITING COMPANY (Check Appropriate Box Below):
❑ MUTUAL OF OMAHA INSURANCE COMPANY For Home Office Use Only
❑ UNITED OF OMAHA LIFE INSURANCE COMPANY
POLICY NUMBER(S) ASSIGNED
located at Mutual of Omaha Plaza, Omaha, NE 68175
•
2. APPLICANT (Full Legal Name) C 141 C Po)
STREET ADDRESS )SG be x r C v■-r
CITY E ) l - STATE ) I i he ` ZIP CODE 6, 0 j CJ
TELEPHONE NUMBER ( i ) 131 - tL 106
3. MEDICAL INFORMATION /////1-
In the space provided on the next page, list all eligible employees, retirees and dependents to whom on the earlier of:
(a) the requested effective date of this policy(ies); or
(b) the date this application is signed,
any of the following conditions apply and who are to be covered under the policy(ies).
1. An employee who is not actively at work at his or her regular workplace because of an injury or illness.
2. A dependent or retired employee who:
a. is disabled, either physically or mentally to the extent of being unable to perform all of the usual and
customary activities (the "normal activities") of a person of the same age or sex who is in good
health; or
b. is covered by your existing group plan as an incapacitated or handicapped child (i.e., a child who
would not be eligible for coverage but for the existence of a physical or mental handicap which
makes the child incapable of self-sustaining employment).
3. An employee, dependent or retiree who:
a. is confined to a hospital, or any other institution or facility other than a hospital or at home or else
where due to any injury or illness.
b. has incurred medical expenses in excess of $25,000 during the past 24 months; or
c. has a chronic or serious medical condition (including but not limited to cancer, heart disease,
disorder of the immune system, alzheimers disease, mental illness, substance abuse).
NOTE: Any employee, retiree or dependent named on the next page will become insured as described
in the policy(ies).
If the plan applied for is a Health and Welfare Fund that utilizes an Hour Bank eligibility, list only
those persons for whom there is no active eligibility through an accrued Hour Bank balance or
those who have continued coverage through a specific Disability continuation provision.
Form 10634GA-MU-EZ HIPAA
Date Disability
•
or Confinement Nature of
Name of Individual Date of Birth Began Disability
(please check if employee (E), dependent (D) or retiree (R)) MM/DD/YY MM/DD/YY or Confinement
E ❑ DO R ❑ / / / /
ED DO R ❑ / / / /
ED D ❑ R ❑ / / / /
ED D ❑ R ❑ / / / /
ED D ❑ RD / / / /
ED D ❑ R ❑ / / / /
(Any Additional Names and Information should be attached on a separate page.)
4. CONTINUATION OF COVERAGE INFORMATION (Complete for medical, dental, prescription drug and vision
benefits.) �/�
List below the requested detail, for ALL employees or dependents whose coverage is to be continued under the
Consolidated Omnibus Reconciliation Act of 1985 (COBRA), State mandated or any other continuation of benefits and
are to be insured under the policy(ies).
Check mark applicable boxes below.
Name of Individual Original
Social Security No. Starting Date of
Continued Coverage *Termination Death Divorce Other (If Other, please explain)
❑ ❑ ❑ ❑
❑ ❑ ❑ ❑
❑ ❑ ❑ ❑
El ❑ ❑ ❑
❑ ❑ ❑ ❑
❑ ❑ ❑ ❑
(Photo this page for additional Names and Information)
*If termination is due to a disability, those individuals must also be listed in 3 above.
Form 10634GA-MU-EZ HIPAA
•
5. THE FOLLOWING IS UNDERSTOOD AND AGREED UPON (UNLESS SPECIFIED IN 7 BELOW.)
(a). An eligible employee who is to be insured under the policy(ies) must be working 30 hours or more a week at
his or her regular work place, or other location to which the employee must travel to perform his or her regular
job duties. Such employees will become insured as described in the policy(ies.)
(b) A retiree or dependent who is to be insured under the policy(ies) and who is:
1. hospital confined;
2. confined in any institution or facility other than a hospital or at home or elsewhere due to an injury or
sickness; or
3. disabled, either physically or mentally, to the extent of being unable to perform all of the usual and
customary duties and activities (the"normal activities") of a person of the same age and sex who is in good
health;
will become insured as described in the policy(ies).
(c) Other eligibility requirements are described in the Eligibility Addendum, which is attached to and made a part
of the policy.
6. Certain states have enacted legislation which requires insurers to provide specific coverage for people residing in or
working in their states. Do you have any eligible employees residing in or working in Arizona, California, Kansas,
Florida, Hawaii, Idaho, Indiana, Maryland or Washington? ❑ Yes tsl. No
If Yes, indicate which state(s)
7. Group Insurance is applied for as specified in the proposal dated with the following
following mooddifications;
L ; n 4G� QSmembu To, pi4
17-,31-irak,ce
•
t,v; u.r\;c -4e (.u.rre h) bf r cz () e cAres, Re)-1-e,5
Lk.) 1 6f. 9 44,_rc�.,4e e Co r C A 1 a I V,coo Lift Ct.3 • 01-1 b e° /7[/rt
If no modifications are shown above, none will be presumed.
8. FINANCIAL CONDITION
Within the last 5 years, has the applicant remained continually solvent? 'pis Yes ❑ No
Does the applicant reasonably expect to be solvent within the next 12 months? Yes ❑ No
If no to either question, please give details.
Solvent means not having filed a voluntary or involuntary petition in bankruptcy, a reorganization or an arrangement
with creditors, or a general assignment for the benefit of creditors, the ability to pay debts as they become due, not
having a trustee, receiver or other custodian appointed on its behalf, or any other case or proceeding under any
bankruptcy or solvency law, or the commencement of any dissolution or liquidation proceeding.
Requested effective date of the policy(ies): 3— 1 -9 9
This application is submitted with the following advance payment: $ ct
Form 10634GA-MU-EZ HIPAA
I understand that the insurer will rely and act upon the answers, statements and any misstatements or omissions of
information that are made on this Application or given and used in the preparation of the Proposal upon which this
application is based. Erroneous information and any material omission of information can result in the rescission,
cancellation or rerating of group insurance coverage issued in reliance thereon.
If this application is not approved by an officer at the Home Office of Underwriting Company, no insurance is in effect at any
time and any advance payment received will be returned.
If this application is approved by an officer at the Home Office of Underwriting Company, it will be attached to and made
a part of the policy. Unless notified in writing of an effective date other than the date shown above, the insurance will begin
on the requested effective date of the policy.
Receipt of the policy and payment of any subsequent premium by the applicant will constitute acceptance of the policy.
For Applicant:
By
\\ (Signature and Title)
Date
NOTICE
THE INFORMATION ON THIS APPLICATION WILL NOT BE USED IN ANY MANNER
THAT IS PROHIBITED BY HIPAA (HEALTH INSURANCE PORTABILITY AND
ACCOUNTABILITY ACT OF 1996) OR ANY APPLICABLE STATE OR FEDERAL
LAWS OR REGULATIONS
Form 10634GA-MU-EZ HIPAA