99-29 Resolution No. 99-29
RESOLUTION
AUTHORIZING EXECUTION OF AN AGREEMENT WITH
RUSH PRUDENTIAL HEALTH PLANS
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 Rush Prudential Health Plans 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
►'S#a i PI l`il►�� j
M E A l T M PL A.Y S
233 S. Wacker Drive,Suite 3900
Chicago IL 60606
REQUEST FOR GROUP INSURANCE
1. Contract Holder's r
• Legal Name: $1
2. Street or P.O.
Address: S Q L ;4- r^
3. City, County, j
State&Zip Code: >✓ �- C- 6
4. Form of Organization ❑Corporation ❑Partnership* ❑Proprietorship* ZIOther(please explain): Mu ., I:+�
*Are Partners or Proprietors to be eligible for insurance? ❑ Yes ❑ No
5. Associated Companies to be included:
Legal Name of Company Location Number Subsidiary Form of
City & State of Em.lovees or Affiliate Organization
6. Coverages Requested: PRush Prudential HMO,Inc. ❑Rush Prudential Insurance Company
❑Rush Prudential HMO(Partners) ❑Rush Prudential POS ❑Rush Prudential PPO
❑Rush Prudential HMO (Affiliates) (For Prudential products,please see attached---> —>)
7. Premiums will be payable on a monthly basis. Monthly premiums may be paid in advance for 12 month periods subject to the
applicable discount. Final rates will be calculated after receipt of enrollment data. The percentage of the premium to be paid by the
Employer is:
Employee Health 1 0 % Dependent Health 7 %
8. Amount of Advance Payment S (Approximately the first monthly premium required).
9. Employment Waiting Period: What period of continuous service on a full-time basis must be completed by an employee before
becoming eligible for insurance: ` k't�e
s-
First of the month following A. month(s)continuous service with the Employer.
Will this apply to present employees? ❑Yes l4No
10. Has this group been insured previously with Prudential or Rush Prudential Health Plans or any other insurance carrier or service plan for
any of the coverages requested? C ❑
Yes ff II No If Yes, indicate coverages,full name of carrier and date of cancellation.
IJ�tie �ross QI S1-t;P. �� p M.0 r11.'tioj S --; -91
If Prudential or Rush Prudential Health Plans,show contract number,original effective date and due date and amount of last paid
premium.
11. Effective Date: 3 / ) / 95 (If Contributory, insurance may not become effective before the required percentage of persons
eligible have enrolled.)
It is understood that no employees shall become insured while not actively at work on full-time at his/her nomal place of business,and only full-time employees shall be
eligible. If coverage is requested for dependents,no dependent shall become covered while confined for medical care or treatment at home or elsewhere.
It is further understood that an application for each contract will be made at the time the contract is delivered:and also that no agent/broker has power on behalf of Rush
Prudential HMO.Inc.for Rush Prudential HMO (formerly Rush Prudential Partners and Rush Prudcential Affiliates)or Rush Prudential Insurance Company for Rush
Prudential POS and Rush Prudential PPO to make or modify an application for insurance.or to bind said Company by making any promise or respresentation or by
giving or receiving any information.
Dated at ) - q q _ / y 47
5
(Full or Corporate Name)
On s 19
(Signature)
•
(Print name&title of Officer, Parmer, or Proprietor)
h:`.home\assg\shared\sales\worddoc\forms\regins.doc Ed.07-97
DISCLOSURE OF K:NOW;N Y1.ft1l Ll.AL \-l./.11/11 /
Rush Prudential HMO and Rush Prudential Insurance Company has, in good faith.offered a proposal for your company's group
insurance coverage based upon information supplied by your company or its representative(s). Included in this information is full
disclosure of all known high amount claims and ongoing medical conditions which may adversely affect the overall risk of your
group insurance program.
Please check the applicable statement and sign below:
1. I am not aware of any of the following:
• Any employee(s)unable to perform his/her duties because of illness or injury.
• Any spouse or dependent that is disabled or confined in a hospital or in any other type of treatment facility,
or at home.
• Any employee or dependent that has incurred medical expenses of S 10,000 or more within the last twelve
months.
• Any employee or dependent currently undergoing treatment which will likely reach S10,000 or more during the
next twelve months.
• Any individuals on COBRA continuation who are disabled or meet any of the criteria listed above.
• Any employee,dependent,or individual on COBRA continuation having a serious medical condition not
included in the preceding statements.
2. 1 t I am aware of individual(s)with conditions as outlined in statement I. above,and have fully disclosed the
requested information below.
3. I 1 I am aware of individual(s)with conditions as outlined in statement I.above,and agree to provide all requested
information below.I also understand that Rush Prudential will review this information and reserve the right to
amend its group insurance proposal based upon this information. In the event of fraud,Rush Prudential reserves
the right to rescind the insurance coverage,
How Lon Mo/Yr Full Name/Address of Doctors.
Name of Person Condition/Details ,Mo/Yr Began Disabled Recovery Practitioners.Hospitals
Date: 1 — 11 ' ct 9 C—1 i 1.1
atute
Print Name and Title of HR/Payroll Officer
Signature •
Print Name and Title of Officer, Partner or Proprietor
1000 IDKMC
1 004 9/11/97
•
Application to
Rush Prudential HMO,Inc.
For Group Contract No. GG-938001
Applicant: CITY OF ELGIN
Address: 1918 North Mendel, Chicago,Illinois 60622
The Group Contract is approved and its terms are accepted.
This Application is made in duplicate. One is attached to the Group Contract. The other is to be returned to
Rush Prudential HMO.
It is agreed that this Application replaces any prior Application for the Group Contract.
CITY OF ELGIN
(Full or Corporate Namji Applicant)
Dated at By 04e,ty_.A-- Q .
V
(Itignature and Title)
On j/l&l cJJ,(19 ? Witness
(To be signed by Resident Agent
where required by law)
THIS COPY IS TO BE RETURNED TO RUSH PRUDENTIAL HMO.
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APP 1001 (938001)A
12
RUSH PRUDENTIAL HMO, INC.
Group Health Care Contract
Contract Holder: CITY OF ELGIN
Group Contract No.: GG-938001
Contract Date: March 1, 1999
Premium Due Dates: The Contract Date, and the first day of each month
beginning with April 1999.
Associated Companies: None
Rush Prudential HMO,Inc.,will arrange or provide the benefits described in Part I of the Certificate of Group
Health Care Coverage,attached to and made a part of the Group Contract,subject to the Group Contract's terms.
This promise is based on the Contract Holder's application and payment of the required premiums.
All the provisions of the Certificate of Group Health Care Coverage,attached to and made a part of the Group
Colt'act,apply to the Group Contract as if fully set forth in the Group Contract.
The Group Contract takes effect on the Contract Date,if the initial premium has been paid and the Group
Contract is duly attested below. It continues as long as the required premiums are paid,unless it ends as
described in its General Rules.
The Group Contract is delivered in and is governed by the laws of the State of Illinois.
60,00ws
Secretary President
1000
COV 1001 (938001)A
1
.
TABLE OF CONTENTS
General Rules
A. Parties 3
B. Definitions 3
C. Included Employers 3
D. Payment of Premiums-Grace Period 3
E. Premium Amounts 4
F. Premium Rate Changes 4
G. Minimum Contribution 4
H. Minimum Participation 4
I. End of The Group Contract 5
• J. Reinstatement 5
K. Mid-Year Transfer Option 5
L. Employee's Certificate or Other Evidence of Coverage 6
M. Information to be Furnished 6
N. The Contract-Incontestability of the Contract 7
O. Notices and Other Information 8
P. Relation Among Parties Affected By The Group Contract 8
Q. Conformity With Law 8
Schedule of Premium Rates 9
Schedule of Plans 10
Application For Group Health Care Coverage 11
Certificates of Group Health Care Coverage
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CTC 1013 (7-1)A
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General Rules
A. PARTIES.
This Group Contract of Health Care Coverage("Group Contract")is entered into between the Contract Holder
and Rush Prudential HMO,Inc. ("Rush Prudential HMO"),an Illinois corporation which is wholly owned by
Rush Prudential Health Plans,an Illinois general partnership.
B. DEFINITIONS.
The terms used in the Group Contract have the meanings set forth in the Group Contract and in the Certificate of
Group Health Care Coverage(or other evidence of Coverage),attached to and made a part of the Group
Contract.
C. INCLUDED EMPLOYERS.
Included Employers under the Group Contract are the Contract Holder and its Associated Companies,if any.
Associated Companies are employers who are the Contract Holder's subsidiaries or affiliates and are listed on the
first page of the Group Contract.
An Employee of more than one Included Employer will be considered an Employee of only one of those
employers for the purpose of the Group Health Care Coverage. That Employee's service with all other Included
Employers will be treated as service with that one.
On any date when an employer ceases to be an Included Employer,the Group Contract will be considered to end
for Employees of that employer. This applies to all of those Employees except those who,on the next day,are
still within the Covered Classes of the Group Contract as Employees of another Included Employer.
The Contract Holder must let Rush Prudential HMO,Inc.know,in writing,when an employer listed as an
Associated Company is no longer one of its subsidiaries or affiliates.
D. PAYMENT OF PREMIUMS-GRACE PERIOD.
Premiums are to be paid by the Contract Holder to Rush Prudential HMO. Premium is due on each Premium
Due Date stated on the first page of the Group Conti act. The Coutiact Holder may pay each premium other than
the first within 31 days of the Premium Due Date without being charged interest. Those days are known as the
grace period. There is no grace period for payment of the first premium. The Contract Holder is liable to pay
premiums to Rush Prudential HMO for the time the Group Contract is in force. Premiums unpaid after the end
of the grace period are subject to a late payment interest charge at an annual rate determined by Rush Prudential
HMO. In no event will that interest rate exceed the maximum allowed by law.
Only a Covered Person for whom the premium is actually received by Rush Prudential HMO shall be entitled to
the benefits of this Group Contract and only for the month for which such payment is received.
Rush Prudential HMO may decide to accept a premium payment after 31 days from the due date. Any such
acceptance does not constitute a waiver of any terms of this Group Contract or the Certificate of Coverage made
a part of the Group Contract.
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GR 1013 (7-1)A
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E. PREMIUM AMOUNTS.
The premium due on each Premium Due Date is the sum of the premium charges for the coverage then provided.
Those charges are determined from the premium rates then in effect and the Employees then covered.
The following will apply if one or more premiums paid include premium charges for an Employee whose
coverage has ended before the due date of that premium. Changes in the employee roster of Covered Persons
may be submitted by Contract Holder no more than 60 days after the effective date of such changes. No such
change shall be made retroactively regarding the termination of a Covered Person if benefits have been provided
to the Covered Person during that period.
F. PREMIUM RATE CHANGES.
The premium rates in effect on the Contract Date are shown in the Group Contract's Schedule of Premium Rates.
Rush Prudential HMO has the right to change premium rates effective as of any of these dates:
1. Any Premium Due Date. However,except for a premium rate change resulting from the events
described in Paragraphs 2.or 3.below,a premium rate change under this Paragraph 1.will not take
effect until the Group Contract has been in force for one year from the Contract Date.
2. Any date that an employer becomes,or ceases to be,an Included Employer.
3. Any date that the extent or nature of the risk under the Group Health Care Coverage is changed:
a. by amendment of the Group Contract or Certificate of Group Health Care Coverage;or
b. by reason of any provision of law or any governmental program or regulation.or
c. by reason of a change in the demographic composition of the group.
Rush Prudential HMO will tell the Contract Holder when a change in the premium rates is made. Rush
Prudential HMO will provide notice of any such change in the premium rate to the Contract Holder not less than
31 days prior to the effective date of such revision. Rush Prudential HMO may not make a change in premium
rates which results in a Covered Person pay more than another similarly situated Covered Person of Codtiact
Holder on the basis of any health-related factor.
G. MINIMUM CONTRIBUTION.
The minimum contribution to be made by an Employer with regard to premiums due for its Covered Persons is
50%.
H. MINIMUM PARTICIPATION.
75%of all Employees eligible to request coverage offered through the Contract Holder must be enrolled in
the Rush Prudential Insurance Company and Rush Prudential HMO, Inc. products offered by the Contract
Holder, combined. In the event that the minimum participation as set forth above falls below 75%,Rush
Prudential HMO may terminate this Group Contract upon 60 days prior written notice.
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GR 1013 (7-1)B
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I. END OF THE GROUP CONTRACT.
The Group Contract may be terminated by Rush Prudential HMO in the event of any of the following:
1. Failure by Contract Holder to pay premiums by the end of the grace period;
2. An act or practice committed by Contract Holder that constitutes fraud,or an omission or misrepresentation
in any materials required to be submitted by Rush Prudential HMO or under the Group Contract,with such
fraud resulting in the rescission of coverage for the group or the individual committing the fraud at the option
of Rush Prudential HMO;
3. Failure by Contract Holder to comply with participation and contribution requirements as set forth herein;
4. Movement of Covered Persons outside the service area of Rush Prudential such that participation
requirements are no longer met;
5. Discontinuance by Rush Prudential HMO of group health insurance coverage,with 90 days prior notice
required to be provided to the Contact Holder;and
6. Discontinuance of all health insurance coverage in the applicable group market by Rush Prudential HMO.
J. REINSTATEMENT.
A Group Contract which has been terminated for failure to pay premiums may be reinstated at the sole discretion
of Rush Prudential HMO. A Contract Holder whose Group Contract is reinstated by Rush Prudential HMO
under this provision shall be charged a$250.00 fee payable to Rush Prudential HMO. A Contract Holder which
is a small group as defined in the Illinois Health Insurance Portability and Accountability Act("Act")shall have
guaranteed availability of subsequent coverage upon provision of all requested information and subject to the
provisions of the Act.
K. MID-YEAR TRANSFER OPTION.
After the Group Contract has been in force for a period of four months during the first year of the contract only,
any Employee of the Contract Holder who is enrolled in Rush Prudential HMO can elect to apply for transfer
(`Mid-Year Transfer Option")of his or her Employee and Qualified Dependents coverage to the PPO plan of
Rush Prudential Insurance Company. In order to be considered for this Mid-Year Transfer Option,the Employee
must complete an enrollment form as supplied by Rush Prudential Insurance Company for a PPO policy during
the first 10 working days of the fifth month during the first year of the contract. The Contract Holder must
complete the Mid-Year Transfer Option form as supplied by Rush Prudential HMO. The Mid-Year Transfer
Option form and enrollment forms must be received by Rush Prudential HMO from the Contract Holder by the
20th day of the fifth month of the Group Contract. In order to be eligible for the Mid-Year Transfer Option the
Employee("Requesting Employee")must comply with the following requirements:
1. All dependents of the Requesting Employee currently enrolled in Rush Prudential HMO must be
transferred to Rush Prudential PPO with the Requesting Employee:
2. Other dependents of the Requesting Employee who were eligible to enroll at the time of the enrollment
but did not then enroll,may not be added at this time;and
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GR 1013 (7-1)C
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K. MID-YEAR TRANSFER OPTION (Continued)
3. None of the members(Requesting Employees and/or dependents)may have used 75%or more of an
HMO benefit that has an annual maximum of days or services.
The Mid-Year Transfer Option will not be approved by Rush Prudential unless the Contract Holder and
Requesting Employee have complied with all the requirements set forth herein in Section K.
If the Mid-year Transfer Option is approved for a Requesting Employee by Rush Prudential,the transfer to the
PPO will be effective on the first day of the sixth month of the contract.
L. EMPLOYEE'S CERTIFICATE OR OTHER EVIDENCE OF COVERAGE.
Rush Prudential HMO will give the Contract Holder an individual certificate(or other evidence of coverage)to
give each covered Employee. It will describe the Employee's coverage.
Such individual certificate will be issued within 30 days from the later of(a)the effective date of the coverage or
(b)the date Rush Prudential HMO is provided completed notification of enrollment. Contact Holder hereby
delegates to Rush Prudential HMO the broadest possible discretion to interpret the terms of the Certificate of
Group Health Care Coverage and the individual certificates given to each covered Employee and to decide
whether benefits are payable thereunder.
M. INFORMATION TO BE FURNISHED.
Rush Prudential HMO will keep a record of the Covered Persons. It will contain the key facts about their
coverage.
The Contract Holder will provide Rush Prudential HMO with all requested information,including but not limited
to medical information,prior to and after the execution of the Group Contract. Further,at the times set by Rush
Prudential HMO,the Contract Holder will send the data required by Rush Prudential to perform their duties
under the Group Counact,and to determine the premium rates. All records of the Coirt.iact Holder and of the
Employer which bear on the Group Health Care Coverage shall be open to Rush Prudential HMO for its
inspection at any reasonable time.
Rush Prudential will not have to perform any duty that depends on such data before it is received in a form that
satisfies Rush Prudential HMO. The Contract Holder may correct wrong data given to Rush Prudential HMO,if
Rush Prudential HMO has not been harmed by acting on it. A person's coverage under the Group Health Care
Coverage will not be made invalid by failure of the Contract Holder or the Employer,due to clerical error,to
record or report the person for the coverage.
The Contract Holder will furnish Rush Prudential HMO the employee and dependents eligibility requirements of
the Employer's Health Benefits Plan that apply on the Contract Date of the Group Contract. Subject to Rush
Prudential HMO's approval,those requirements will apply to the Employee and Dependents Coverage under the
Group Health Care Coverage. The Contract Holder will notify Rush Prudential HMO of any change in the
eligibility requirements of the Employer's Health Benefits Plan,but no such change will apply to the Employee or
Dependents Coverage under the Group Health Care Coverage unless approved in advance by Rush Prudential
HMO.
The Contract Holder will notify Rush Prudential HMO of any event,including a change in eligibility,that causes
termination of a Covered Person's coverage. Such notification will be made within 60 days of the effective date
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GR 1013 (7-1)C
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M. INFORMATION TO BE FURNISHED (Continued)
of the event. The liability of Rush Prudential to arrange or provide benefits for a person ceases when the person's
coverage ends. If the Contract Holder fails to notify Rush Prudential HMO as provided above,Rush Prudential
will be entitled to reimbursement from the Contract Holder of the reasonable cash value of any benefits arranged
or provided to any person after the person's coverage has ended.
N. THE CONTRACT-INCONTESTABILITY OF THE CONTRACT.
The entire contract consists of:the pages that make up the Group Contract;the Certificates of Group Health Care
Coverage(or other evidence of coverage)that are attached to and made a part of the Group Contract;the
Contract Holder's application,a copy of which is attached to and made part of the Group Contract;any riders,
endorsements or amendments to the Group Contract and Certificate of Group Health Care Coverage; and the
individual applications,if any,of the persons covered. No statement of the Contract Holder will be used in any
contest of the Coverage under the Group Contract.
There will be no contest of the validity of the Group Contract,except for failure to pay premiums,after it has
been in force for one year.
•
The Group Contract may be amended,at any time,without the consent of the Covered Persons or of anyone else
with a beneficial interest in it. This can be done through written request made by the Contract Holder and agreed
to by Rush Prudential HMO. Rush Prudential HMO may also make amendments to the Group Contract,as
provided in(2)and(3)below. Rush Prudential HMO has the discretion contractually to modify the Group
Contract at any time. Any such modification must be mutually agreed to by Rush Prudential HMO and the
Contract Holder. An amendment will not affect benefits for a service or supply furnished before the date of
change.
Only an officer of Rush Prudential HMO has authority:to waive any conditions or restrictions of the Group
Contract;or to extend the time in which a premium may be paid;or to make or change a contract;or to bind
Rush Prudential by a promise or representation or by information given or received.
No change in the Group Contract is valid unless the change is shown in one of the following ways:
1. It is shown in an endorsement on it signed by an officer of Rush Prudential HMO.
2. In the case of a change in the Group Contract that has been automatically made to satisfy the requirements of
any state or federal law that applies to the Group Contract,as provided in the Conformity with Law section,
it is shown in an amendment to it that is signed by an officer of Rush Prudential HMO.
3. In the case of a change required by Rush Prudential HMO,it is shown in an amendment to it that:
a. is signed by an officer of Rush Prudential HMO;and
b. is accepted by the Contract Holder as evidenced by payment of a premium becoming due under
the Group Contract on or after the effective date of such change.
4. In the case of a written request by the Contract Holder for a change,it is shown in an amendment to it signed
by the Contract Holder and by an officer of Rush Prudential HMO.
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GR 1013 (7-1)D
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O. NOTICES AND OTHER INFORMATION.
Any notices,documents,or other information under the Group Contract may be sent by United States Mail,
postage prepaid,addressed as follows:
If to Rush Prudential HMO: To its address shown on the first page of the Certificate of Group Health Care
Coverage(or in any other evidence of coverage).
If to a Covered Person: To the last address provided by the Covered Person on an enrollment or change of
address form actually delivered to Rush Prudential HMO.
If to the Contract Holder: To the last address of the Contract Holder on record with Rush Prudential HMO.
P. RELATION AMONG PARTIES AFFECTED BY THE GROUP CONTRACT.
The relationship between Rush Prudential and any Hospital is that of an independent contractor. No Hospital is
an agent or employee of Rush Prudential,nor is Rush Prudential or any employee of Rush Prudential any
employee or agent of any Hospital. Each Hospital will maintain the hospital-patient relationship with Covered
Persons under the Group Contract and is solely responsible to Covered Persons for Hospital supplies and
services.
The relationship between Rush Prudential and any Participating Health Care Providers is that of an independent
contractor. No Participating Health Care Provider is an agent or employee of Rush Prudential,nor is Rush
Prudential or any employee of Rush Prudential an employee or agent of a Participating Health Care Provider.
Each Participating Health Care Provider will maintain the provider-patient relationship with the Covered Persons
under the Group Contract and is solely responsible to Covered Persons for supplies and services furnished to
Covered Persons.
Neither the Contract Holder nor any Covered Persons under the Group Contract is the agent or representative of
Rush Prudential. Neither the Contract Holder nor any Covered Person under the Group Coutiact will be liable
for any acts or omissions: (a)of Rush Prudential,its agents or employees;or(b)of any Hospital or other health
care provider with which Rush Prudential,its agents or employees make arrangements for furnishing supplies and
services to Covered Persons.
Employer has delegated to Rush Prudential the broadest possible discretion to interpret the terms of the Booklet
and to determine which benefits under the terms of the Certificate the Employee and his/her eligible dependents
are entitled to receive.
Q. CONFORMITY WITH LAW.
If the provisions of the Group Contract do not conform to the requirements of any state or federal law or
regulation that applies to the Group Contract,the Group Contract is automatically changed to conform with Rush
Prudential's interpretation of the requirements of that law or regulation consistent with the Illinois Department of
Insurance.
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GR 1013 (7-1)E
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Schedule of Premium Rates GG-938001
Classes of Employees to which this Schedule applies:
All classes
Monthly Rate Per Employee
Rush Prudential HMO
Single Family
Group Health Care Coverage $147.72 $406.23
The rates shown above for Employee Coverage will no longer apply to an Employee's Employee Coverage when
the Employee is or could be covered under Medicare and Federal law does not require that Medicare take other
group health care benefits into account when determining Medicare's benefits.
Also,the rates shown above for Dependents Coverage will no longer apply to an Employee's Dependents
Coverage when the Employee has a Qualified Dependent spouse who is or could be covered under Medicare and
Federal law does not require that Medicare take other group health care benefits into account when determining
Medicare's benefits.
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SPR 1001 (938001)A
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Schedule of Plans
Effective Date: March 1, 1999
Group Contract No.: GG-938001
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 CITY OF ELGIN permanently residing in the Service Area.
Plan of Benefits that Applies to this Covered Class:
The benefits described in the Rush Prudential HMO Certificate of Group Health Care Coverage
as forms in the Rush Prudential HMO Member Guide and Certificate bearing the code HMO
Cert 10/96.
And includes the following forms: Rush Prudential HMO schedule of copayments prepared for
Group No. 938001: Rider Nos. 41,211,218, 373, 381, 58,342,400,20126.
•
•
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SCP 1001 (938001)A
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Application to
Rush Prudential HMO,Inc.
For Group Contract No. GG-938001
Applicant: CITY OF ELGIN
Address: 1918 North Mendel, Chicago,Illinois 60622
The Group Contract is approved and its terms are accepted.
This Application is made in duplicate. One is attached to the Group Contract. The other is to be returned to
Rush Prudential HMO.
It is agreed that this Application replaces any prior Application for the Group Contract.
CITY OF ELGIN
.ull or Corporate Name o :pplicant)
Dated at w By iu.. I. %.
ignature and Title)
On -3/0 , 19 9/ Witness
(To be signed by Resident Agent
where required by law)
THIS COPY MAY BE RETAINED FOR YOUR FILES.
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APP 1001 (938001)A
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