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03-48 Resolution No. 03-48 RESOLUTION ACCEPTING THE PROPOSAL OF JEFFERSON PILOT FINANCIAL INSURANCE COMPANY FOR GROUP LIFE INSURANCE AND ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE AND AUTHORIZING THE EXECUTION OF DOCUMENTS RELATED THERETO BE IT RESOLVED BY THE CITY COUNCIL OF THE CITY OF ELGIN, ILLINOIS, that the City of Elgin hereby accepts the proposal of Jefferson Pilot Financial Insurance Company for group life insurance and accidental death and dismemberment insurance for the period commencing March 1, 2003 . BE IT FURTHER RESOLVED that Olufemi Folarin, Interim City Manager, be and is hereby authorized and directed to execute all documents necessary and incident to such proposal of Jefferson Pilot Financial Insurance Company. s/ Ed Schock Ed Schock, Mayor Presented: February 26, 2003 Adopted: February 26, 2003 Omnibus Vote : Yeas : 6 Nays : 0 Attest : s/ Dolonna Mecum Dolonna Mecum, City Clerk r © JEFFERSON PILOT FINANCIAL February 26,2003 Mr.Nick Oriti City of Elgin 150 Dexter Ct. Elgin,IL 60121-5555 Re: City of Elgin Life/AD&D Insurance Effective Date: March 1,2003 Dear Mr. Oriti: Enclosed please find the revised Contract/Application page(s)showing the correct age reduction schedule and the correct maximum benefit for Class 2. Also enclosed is a revised proposal showing these revisions. Please attach these documents to the previous contract that I sent you, and return the signed letter with your binder check previously discussed. Your cooperation and your business are greatly appreciated! Please call feel free to call me if you have any questions. Sincerely, 0-_A� Armand D'A drea Accepted by 4116% _ Print Name -31181 Title �����Z•y �dK Atk_ Cc: Kurt Schmitke/Global Benefits,Inc. A GROUP INSURANCE PROGRAM Designed for CITY OF ELGIN Submitted by Global Benefits Inc. Lincolnshire, IL Underwritten by JEFFERSON PILOT FINANCIAL INSURANCE COMPANY 8801 Indian Hills Drive Omaha, Nebraska 68114 CTYELGN 2163142 City of Elgin SCHEDULE OF INSURANCE Option 1.02 Proposed Effective Date: March 01, 2003 CLASSIFICATION AMOUNT OF BENEFIT Life Accidental Death Insurance and Dismemberment (24 Hour) Class 1 All Eligible Elected Officials 20,000 20,000 Class 2 All Eligible Management, Supervisory and 1.00 times annual salary, Professional Employees rounded to the next higher 1,000, subject to a maximum of 210,000 Class 3 All Eligible Police Officers 35,000 35,000 Class 4 All Eligible Public Service Employees 20,000 20,000 Class 5 All Eligible Fire Fighters and Fire Lieutenants 40,000 40,000 Class 6 All Eligible Clerical/Technical Employees 30,000 30,000 The amount of Life Insurance and AD&D for Class 1, 2, 3, 4, 5, 6 will reduce: -to 65% of the original amount upon the Person's attainment of age 70 -by an additional 20% of the original amount at age 75 -by an additional 10% of the original amount at age 80 Benefits will terminate upon retirement. Jefferson Pilot Financial Insurance Company 3 2/28/2003 CTYELGN 2163142 • City of Elgin Annual Salary means only the salary or wage an Insured Person receives for services rendered to the Group Policyholder. It does not include bonuses, overtime pay or other extra compensation other than commissions. Commissions will be averaged over the 12 month period prior to the date disability begins. Guarantee Issue Amount: 210,000 Jefferson Pilot Financial Insurance Company 4 2/28/2003 CTYELGN 2163142 City of Elgin SCHEDULE OF RATES AND COSTS Number of Monthly Coverage Employees Volume Rate Premium Life Insurance 646 26,085,500 $.17/per $1,000 of benefit $4,434.54 AD&D 646 26,085,500 $.040/per$1,000 of benefit $1,043.42 Total Premium $5,477.96 The above rates assume the Life coverage is on a non-contributory basis and 100% participation is required. The AD&D coverage includes the Safe Driver Benefit (Seat Belt & Air Bag Benefit) and Common Carrier Benefit. The above rates are guaranteed for Two Years from the effective date of coverage. This proposal describes certain insurance coverages available from Jefferson Pilot Financial and should under no circumstances be construed as a contract or offer to contract for such coverages. An application must be completed and submitted to our Omaha Office, before a group will be considered for coverage. If the proposed policy qualifies as a replacement plan, then coverage for an otherwise eligible person who is disabled on the policy effective date will be administered in accord with any applicable state discontinuance and replacement law. The proposal is based on preliminary census data received by Jefferson Pilot Financial. Actual costs will be based on the final enrollment data of employees insured under the plan on its effective date. Rates quoted for the proposed benefits shown are effective for 90 days from the date shown on the proposal. A complete listing of the terms, conditions, and limitations, that will apply to your coverage, if issued, is available upon request. Jefferson Pilot Financial Insurance Company 5 2/28/2003 d1 Jefferson Pilot Financial Insurance Company,Omaha,NE I Office Use Only-ID# A. CLASSES FOR LIFE&AD&D BENEFITS LIFE&AD&D BENEFITS SUPPLEMENT CLASS 1 DESCRIPTION COVERAGES BENEFITS ❑ Basic Life Basic Benefit Amount(select one): ❑ Basic AD&D ❑Flat benefit amount$ ❑Multiple of salary: ❑1X ❑2X ❑3X ❑Other Subject to$ Minimum and $ Maximum ❑ Optional Life Rounded to next higher$1,000 unless requested otherwise below. ❑ Optional AD&D ❑Other Dependent Life(may not exceed state limits): Basic Optional ❑ Basic Spouse(Coverage terminates at age 70) $ $ Employer Contribution for Basic Dependent Life Life/AD&D % ❑ Optional Child(14 Days-6 Mo.) $ $ ptional Child(6 Mo.-19 Yrs.;23 Yrs.if full-time student)$ $ Dependent Life era limits apply in: LA-21 Yrs;24 Yrs.if full-time student. In OK-to age Employer Contribution for Dependent (Higher PPly Life % 21,or older if full-time student. In SC,19 Yrs;25 if full-time student.) Optional Benefit Amount(describe): CLASS 1 EARNINGS DEFINITIONS Complete Only for Salary Based Plan. In no event will salary exceed the amount shown in the Employer's payroll records,or for which premium has been paid(if less). ❑ Earnings standardly include annual base salary,or amualized hourly pay(excluding overtime)and any commissions averaged over prior 12 Months. Earnings are determined on the last day worked. If any other compensation is to be included or an alternate definition is wanted,describe below: Also include: Instead base on: ❑Bonuses averaged over 36 Months. ❑Each Employee's W-2 earnings for prior year. ❑Other(subject to Home Office Approval ❑Other(subject to Home Office Approval) CLASS 2 DESCRIPTION COVERAGES BENEFITS Ai ` 'A.(C --a; ,_ © Basic Life Basic Benefit Amount(select one): . A ® Basic AD&D ❑Flat benefit amount$ t �0.v1 a��,11w-Q e t,t..}. tz Multiple of salary: ®1X ❑2X ❑3X ❑Other 1 t ` Subject to$10 o Minimum and $2.1b,800 Maximum . p p vv i So G r ❑ Optional Life ❑Rounded to next higher$1,000 unless requested 6therwise below. n S,��CIt �niP ❑ Optional AD&D Other Dependent Life(may not exceed state limits): Basic Optional Employer Contribution for Basic ❑ Basic Spouse(Coverage terminates at age 70) $ $ Dependent Life Child(14 Days-6 Mo.) $ $ LifelAD&D 10 C) % ❑ Optional Child(6 Mo.-19 Yrs.;23 Yrs.if full-time student)$ $ Employer Contribution for Dependent Dependent Life (Higher age limits apply in: LA-21 Yrs;24 Yrs. if full-time student. In OK-to age Life % 21,or older if full-time student. In SC,19 Yrs;25 if full-time student.) Optional Benefit Amount(descrbe): CLASS 2 EARNINGS DEFINITIONS-Complete Only for Salary Based Plan. In no event will salary exceed the amount shown in the Employer's payroll records,or for which premium has been paid(if less). Must be the same for all classes if list billed. ❑ Earnings standardly include annual base salary,or annualized hourly pay(excluding overtime)and any commissions averaged over prior 12 Months. Earnings are determined on the last day worked. If any other compensation is to be included or an alternate definition is wanted,describe below: Also include: Instead base on: ❑Bonuses averaged over 36 Months. ❑Each Employee's W-2 earnings for prior year. ❑Other(subject to Home Office Approval) ❑Other(subject to Home Office Approval) (Attach separate sheet for additional classes) GL2-Life Supp. Rev.07101 (over) Rt.%) _Ott 066S S) B. PARTICIPATION Total Number of Eligible Employees 4 q Number with Eligible Dependents Number to be insured for Life/AD&D 6,q Number to elect Dependent Life C. AGE REDUCTIONS AND TERMINATIONS FOR ALL CLASSES 1. Age Reductions-Life and AD&D Benefits reduce 35%at age 65,another 25%of the original amount at 70,and another 15%of the original amount at 75;unless requested otherwise. ®Other(Specify) j:vAuc e 5 to 4,5% p a3 e 70 S a n addi=1-ioni 20`i,› & — '75 ; ar. attd i-ifor t( to/G Q � go 2. Termination-Life and AD&D Benefits standardly terminate a retir ent(recommended for compliance with age discrimination la unless requested otherwise. ❑Other(Specify) D. REPLACEMENT COVERAGE ®Yes ❑No Will all or part of this plan supplement or replace similar life and/or AD&D coverage? If Yes,provide details below and enclose a copy of each contract to be replaced or supplemented. If replacement,prior insurance credit will be provided. Prior Carrier Effective Date of Prior Plan Termination Date of Prior Plan M(A+,....al of ©nna har O )5/D i/O O O 3/( 1 /O 3 REMARKS(Identify by section name and item number) FOR HOME OFFICE USE ONLY GL2-Life Supp. Rev.07/01 - . . 19829 Jefferson Pilot Financial Insurance Company INVOKE CITY OF ELGIN DATE ELGIN, ILLINOIS P.O. NUMBER MO DAY YR INVOICE NO. AMOUNT DISCOUNT NET I AD & D and Life Insuranc 635-0000-796-5002 5,477. 96 Premium for: March 2D03 I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I TOTAL 5,477. 96 FAL r RISK MAP,ACZ:ZZ,:T ACCOUNT - , r , - ,— , . , ,,, ttP1;11 ' Icttn. 7o-45 ns i r 401651 , MO DAY ,YEAR PAY TO THE ORDER OF: 103 1031 031 PAY I *5,477.1_ 961, r n VOID AFTER SIX MONTHS 1 Jefferson Pilot Financial Insurance Co. CITY OF ELGIN, ILLINOIS , , / L _1 Amcore Bank i Elgin,Illinois • i-• --if L ---4.-i' i ,*----t • 11'00 39 3 2111 1:0 7 1900 to 561: 0 L 5 4 7 3011° ,....t..4- tho,....r.c - 36-1,.../.,,) sib-",..,-J, 4...-&.r..r ihm a....Y...0. 111.1..e.." Ah.7...1%.4" 116.7...r.„A 31.7.,,,,rse al.7...,../` .4.7..e...4. 1111,1.,,tr, Am■----- APPLICATION FOR GROUP INSURANCE Jefferson Pilot Financial Insurance Company 8801 Indian Hills Drive Omaha,Nebraska 68114-4066 GENERAL INFORMATION Application for group insurance is hereby made to JEFFERSON PILOT FINANCIAL INSURANCE COMPANY/the Company). Office Use Only:ID# A. NAME AND ADDRESS 1. Applicant's Full Legal Name(exactly as to be shown in Group Policy): City of Elgin 2. Main Office Address(physical location and group situs state): Street 150 Dexter Court City Elgin State IL Zip 60120-5555 Phone#.(847) 931-6040 FAX#( (847) 931-5906 E-Mail Address (if available) 3. Administrator Name Nick Oriti Mailing Address(if different): P.O. Box(if any) Street City State Zip Phone#, FAX/1( E-Mail Address (if available) B. REQUESTED COVERAGES 1. Requested Effective Date of insurance(month/day/year): March 1, 2003 2. Coverages elected and Benefits Supplement Form to be completed for each coverage: © Basic Lite and AD&D-Complete Life Benefit Supplement J Indemnity Dental-Complete Dental Benefit Supplement ❑Short Term Disability-Complete STD Benefit Supplement E1 Dental PPO(where available)-Complete PPO Supplement ❑Long Term Disability-Premier Plan-Complete LTD PP Supplement El Scheduled Benefit Dental Plan-Complete SBP Supplement ❑Long Term Disability-Value Plan-Complete LTD VP Supplement C. BUSINESS INFORMATION 1. Nature of Business(Please specify): Municipality Years in Business 100+ Federal Tax ID# 2. Business is Organized As(select one): ❑Corporation ©Non-Profit Organization Partnership ❑Proprietorship ❑Other 3. Financial Risk(If Yes to any part,please explain below.) ❑Yes © No Has Applicant ever filed for bankruptcy? El Yes © No Does Applicant anticipate ceasing or materially reducing active business operations? Ej Yes n No Has Applicant opted out(or do they anticipate opting out)of Workers'Compensation? Explanation: 4. Funding-Employer premium contributions will be funded from: © General Assets Section 125/Cafeteria Plan GL2-APP.02/02 1 (over) General lnfmmation Eon n...continued £ S TA 1 F REQUIRED FRAUD WARNINGS COLORADO: IT IS UNLAWFUL TO KNOWINGLY PROVIDE FALSE, INCOMPLETE,OR MISLEADING FACTS OR INFORMATION TO AN INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING OR ATTEMPTING TO DEFRAUD THE COMPANY. PENALTIES MAY INCLUDE IMPRISONMENT, FINES,DENIAL OF INSURANCE AND CIVIL DAMAGES. ANY INSURANCE COMPANY OR AGENT OF AN INSURANCE COMPANY WHO KNOWINGLY PROVIDES FALSE, INCOMPLETE, OR MISLEADING FACTS OR INFORMATION TO A POLICYHOLDER OR CLAIMANT FOR TIE PURPOSE OF DEFRAUDING OR ATTEMPTING TO DEFRAUD THE POLICYHOLDER OR CLAIMANT WITH REGARD TO A SETTLEMENT OR AWARD FROM INSURANCE PROCEEDS SHALL BE REPORTED TO THE COLORADO DIVISION OF INSURANCE WITHIN THE DEPARTMENT OF REGULATORY SERVICES. KENTUCKY:ANY PERSON WHO KNOWINGLY AND WITH THE INTENT TO DEFRAUD AN INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR INSURANCE CONTAINING ANY MATERIALLY FALSE INFORMATION OR CONCEALS, FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO,COMMITS A FRAUDULENT INSURANCE ACT,WHICH IS A CRIME LOUISIANA: ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR KNOWINGLY PRESENTS FALSE INFORMATION IN AN APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES AND CONFINEMENT IN PRISON. NEW MEXICO: ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR KNOWINGLY PRESENTS FALSE INFORMATION IN AN APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO CIVIL FINES AND CRIMINAL PENALTIES. OHIO:A PERSON COMMITS INSURANCE FRAUD, IF HE OR SHE SUBMITS AN APPLICATION OR CLAIM CONTAINING A FALSE OR DECEPTIVE STATEMENT WITH INTENT TO DEFRAUD(OR KNOWING THAT HE OR SHE IS HELPING TO DEFRAUD)AN INSURANCE COMPANY. PENNSYLVANIA:ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION OR CONCEALS FOR THE PURPOSE OF MISLEADING,INFORMATION CONCERNING ANY FACT MATERIAL THERETO,COMMITS A FRAUDULENT INSURANCE ACT,WHICH IS A CRIME AND SUBJECTS SUCH PERSON TO CRIMMINAL AND CML PENALTIES. Other states:A PERSON MAY BE COMMUTING INSURANCE FRAUD, IF HE OR SHE SUBMITS AN APPLICATION CONTAINING A FALSE OR DECEPTIVE STATEMENT WITH THE INTENT TO DEFRAUD(OR KNOWING THAT HE OR SHE IS HELPING TO DEFRAUD)AN INSURANCE COMPANY. E AGREEMENT The Applicant hereby applies for group insurance as provided in the attached Supplements,which are made a part of this Application. The information in this Application is Due and correct to the best of the Applicant's knowledge and belief. It forms the basis for this request for group insurance. Omission or misstatement of known information on this Application could affect the validity of any insurance issued and cause the denial of an otherwise valid claim. The Applicant understands that the requested group insurance will: (a) be issued only if the requested insurance is acceptable to Jefferson Pilot Financial Insurance Company(the Company)and is legally permissible; (b) be issued under a group Policy or Policies in the language customarily used by the Company; (c) be subject to the Company's usual underwriting requirements(including Evidence of Insurability,if applicable); (d) be subject to all exclusions and limitations of the Poky;and (e) take effect on the date determined by the Company. The Applicant understands that no agent or broker has the authority to guarantee the acceptability of the requested insurance. The effective date of insurance for which an employee is rewired to submit satisfactory Evidence of Insurability will be determined in accord with the Policy's terms,and wil be subject to the Active Work requirement. The Applicant agrees not to: (a) collect or pay premiums(other than the Binder Premium)for such insurance,before receiving the Company's notice of approval;or (b) distribute material describing Policy coverage to persons to be insured,without the Company's prior written consent. If dental insurance is re quested,the Applicant agrees to provide employees and dependents notice of any a 'cable continuation rights,required by federal COBRA law or any similar state continuation law. Premium rate quotes were based on data submitted to the any.Final premium rates will be determined by the actual composition of the group. This application and the payment of premium constitutes the consideration for any Policy issued. After receipt of the Policy, Office t of premium is acceptance of the Policy's terms(including any correct ions,additions or changes shown in the spaces marked"For Home Only"). Application,including the attached Supplements,shall be made a part of any Policy issued. Writing Agent r/ Signed by Applicant's Authorized Representative: Or Broker's Signature 1,ytyF} ,. ) Typed or Printed Name /t• JV , YP� I��cmrrt— SCan�-t r�t�.p Signature License Number. 3( (2 5--Le 3- State i-U- Typed or Printed Name 'A'S 4' exto#T. 6 Ilia.( Ben o + , Title - 440•0.46q". State Signed: ��i Date I I j r (Must be signed prior to Effective Date) GL2•APP.02/01 2 Rev.09/01 • F• ADMINISTRATIVE INFORMATION Administrative Guide and forms can be found on-line at www4pfinanciaLcom. 1. Group Administrative Guide: Indicate format desired: ❑ CD ROM © Paper Binder 2. Shipping Address for Group Administrative Guide and supplies(Do not show P.O.Box): Name/Firm City of Elgin / Attn: Nick Oriti Street 150 Dexter Court City Elgin State IL ZIP60120 3. Does Applicant have any other group policy inforce with the Company? ❑Yes © No If Yes,show Policy Number(s)if known 4. Binder payment submitted: Amount$ 5 9 36,, 97 5. Type of Policy Administration: ©List Billing by the Company* ❑Self-Administration ❑Billing by Third Party Administrator** *If List-Billed group requires separate billing locations,please complete Section I and/or J. **TPA Agreement and copy of TPA license must be on file with the Company. G. ELIGIBILITY,WAITING PERIOD If requirements differ by coverage types,please explain below(or complete a sheet for each plan). 1. Eligible Classes will be as described in each Benefits Supplement Form. Minimum Hours-All Eligible Employees must work a minimum of 30 regularly scheduled hours per week. Standard is 30 hours. 2. Eligibility Waiting Period A. Present Employees(hired on or before the Effective Date of this Policy)who have not yet satisfied the new employee Eligibility Waiting Period: ❑must also complete the new employee Eligibility Waiting Period before becoming eligible for insurance ❑will not be required to satisfy an Eligibility Waiting Period before becoming eligible for insurance © must be employed in an eligible class for 0 days before becoming eliaible for insurance B. New Employees(hired after this Policy's Effective Date)must be employed in an eligible class with the Applicant for 0 days before becoming eligible for insurance. 3. Employee Effective Date-Subject to the Active Work rule,employees become insured on: ❑ 1st day of employment(If no Eligibility Waiting Period) © 1st day of the insurance month coinciding with or next following completion of the Eligibility Waiting Period ❑The day following completion of the Eligibility Waiting Period ❑Other(must be approved by the Home Office) 4. Excluded Classes-The Policy standardly excludes retirees,temporary,seasonal or part-time employees working less than the Minimum Hours selected. Also exclude the following: NOTE: Subject to Active Work Rule, benefit increases will take effect on the 1st day of the insurance month coinciding with or next following the increase,unless requested otherwise in REMARKS and agreed upon by the Company. Decreases will take effect on the date of the change. H. ERISA PLAN INFORMATION 1. Summary Plan Description (SPD) - ERISA requires distribution of SPDs for most employee benefit plans. The Certificate can serve as the SPD, if certain plan i mation and a Statement of ERISA Rights are added. ❑Yes Vj No Should ERISA information be included to form a combined SPD/Certificate? If Yes,supply information below. A. Plan Year ends on each (month and day). B. Plan Number assigned to each line of coverage by Applicant(3 digits starting with"5"--501,502,etc.): life/AD&D STD LTD Dental 2. Other information to be included in SPD,complete if applicable. A. Plan Administrator or Fiduciary: ❑Same as Applicant ❑Other as shown below Name/Title Phone( Address City State ZIP B. Agent for Service of Legal Process,Plan Trustees,Relevant Union Contract,if applicable: Plan fiduciary Responsibilities: Jefferson Pilot financial Insurance Company cannot be named a plan fiduciary and shall not be responsible for any tax or legal aspects of the employer's plan. The employer is responsible for compliance with tax,employment and fringe benefits laws,and for obtaining any necessary counsel from their own tax and legal advisors.The Company's obligations are governed solely by the Policy. 6L2-APP.02102 3 (over) General Information Form...continued I. SUBSIDIARY OR AFFILIATE INFORMATION(Complete only if separate firm is to be added. Attach a separate sheet for additional Units.) A "Subsidiary" or"Affiliate" is a separate firm which is owned or controlled by the Applicant. Its employees will be insured under the Policy only if requested below and approved by the Company. Please complete the following for each subsidiary or affiliate to be insured under the Policy. Unit Name Unit's Total Eligible Employees No.selecting each coverage Physical Address City State Zip Mailing Address(If different) City State Zip Nature of Unit's Business is 0 Same Other Is separate billing required? El Yes El No Contact Person Binder payment amount for this Billing Unit: $ J. DIVISION INFORMATION(Complete for a division which is in a different location/industry or requires a separate billing location. Attach a separate sheet for additional Units.) A"Division"is a subdivision,branch or location of the Applicant's same firm. It will be automatically included under any Policy issued;unless its employees are listed as an excluded class in the Eligibility section of your General Information Form. Complete the following for each division to be insured under the Policy,if: (a)it is in a different location;(b)it is engaged in a different business or industry;or(c)a separate billing location is required. Unit Name Unit's Total Eligible Employees lo.selecting each coverage Physical Address City State Zip Mailing Address(If different) City State Zip Nature of Unit's Business is ❑Same ❑Other Is separate billing required? ❑Yes ❑No Contact Person Binder payment amount for this Billing Unit: $ REMARKS (Identify by section name and item number) FOR HOME OFFICE USE ONLY GL2-APP.2002 4 Jefferson Pilot Financial Insurance Company, Omaha,NE Office Use Only-ID# A. CLASSES FOR LIFE&AD&D INSURANCE LIFE&AD&D BENEFITS SUPPLEMENT CLASS 1 DESCRIPTION COVERAGES BENEFITS All Elected Officials © Employee Employee Basic Term life Benefit Amount(select one): Basic Life © Flat benefit amount$ 20, 000.00 © Basic AD&D ❑Multiple of salary: ❑IX ❑2X ❑3X ❑Other Subject to$ Minimum and $ Maximum ❑ Accident Plus "Unavailable in OK Rounded to next higher$1,000 unless requested otherwise below. ❑Other ❑ Optional Life Dependent Life(may not exceed state limits): Basic Optional ❑ Optional AD&D Spouse(Coverage terminates at age 70) $ $ Employer Contribution for Basic Child(14 Days-6 Mo.) S S Life)AD&D 100% ❑ Basic Child(6 Mo.- 19 Yrs.;23 Yrs.if full-time student)$ $ Dependent Life Higher age limits apply: In LA-21 Yrs;24 Yrs.if full-time student. In OK-to age 21, Employer Contribution for Dependent ❑ Optional or older if full-time student. Life y, Dependent Life Optional Benefit Amount(describe): Note: Stand-alone benefits for Dependent Liie, Child Life or AD&D are not available. Accident Plus is available only for the Employee with Basic AND. CLASS 1 EARNINGS DEFINITIONS-Complete Only for Salary Based Plan. In no event will salary exceed the amount shown in the Employer's payroll records,or for which premium has been paid(if less). © Earnings standardly include annual base salary,or annualized hourly pay(excluding overtime)and any commissions averaged over prior 12 Months. Earnings are determined on the last day worked. If any other compensation is to be included or an alternate definition is wanted,describe below: Also include: Instead base on: ElBonuses averaged over 36 Months. ❑Each Employee's W-2 earnings for prior year. Other(subject to Home Office Approval ❑Other(subject to Home Office Approval) CLASS 2 DESCRIPTION COVERAGES BENEFITS All Full-Time 9 Employee Basic Employee Basic Term Life Benefit Amount(select one): Life ❑Flat benefit amount$ Management, 9 Basic AD&D 9 Multiple of salary: 9 1X U 2X d 3X ❑Other ❑ Accident Plus' Subject to$10. 0 0 0.C Minimum and $ 100,000. Maximum Supervisory and "Unavailable in OK Rounded to next higher$1,000 unless requested otherwise below. ❑Other Professional Employee ❑ Optional Life Dependent Life(may not exceed state limits): Basic Optional ❑ Optional AD&D Spouse(Coverage terminates at age 70) $ $ Employer Contribution for Basic Child(14 Days 6 Mo.) $ $ Employer 100 Contribution Child(6 Mo.-19 Yrs.;23 Yrs.if full-time student)$ $ ❑ Basic Higher age limits apply: In LA-21 Yrs;24 Yrs.if full-time student. In OK-to age 21, Employer Contribution for Dependent Dependent Life or older if full-time student. Life % ❑ Optional Dependent Life Optional Benefit Amount(describe): Note: Stand-alone benefits for Dependent Life, Child Life or AD&D are not available. Accident Plus is available only for the Employee with Basic AD&D. CLASS 2 EARNINGS DEFINITIONS -Complete Only for Salary Based Plan. In no event will salary exceed the amount shown in the Employer's payroll records,or for which premium has been paid(if less). Must be the same for all classes if list billed. 9 Earnings standardly include annual base salary,or annualized hourly pay(excluding overtime)and any commissions averaged over prior 12 Months. Earnings are determined on the last day worked. If any other compensation is to be included or an alternate definition is wanted,describe below: Also include: Instead base on: ❑Bonuses averaged over 36 Months. ❑Each Employee's W-2 earnings for prior year. ❑Other(subject to Home Office Approval) ❑Other(subject to Home Office Approval) (Attach separate sheet for additional classes) GL2-Life Supp.02 (over) Jefferson Pilot Financial Insurance Company,Omaha,NE ( Office Use Only•ID N A. CLASSES FOR LIFE&AD&D INSURANCE LIFE&AD&D BENEFITS SUPPLEMENT CLASS39ESCRIPTION COVERAGES BENEFITS All Full-Time Police © Employee Employee Basic Term Life Benefit Amount(select one): Basic Life © Flat benefit amount S 35,000.00 Officers © Basic AD&D ❑Multiple of salary: ❑1X ❑2X ❑3X ❑Other ❑ Accident Plus* Subject to$ Minimum and $ Maximum "Unavailable in OK Rounded to next higher$1,000 unless requested otherwise below. ❑Other ❑ Optional Life Dependent Life(may not exceed state limits): Basic Optional ❑ Optional AD&D Spouse(Coverage terminates at age 70) $ $ Employer Contribution for Basic Child(14 Days 6 Mo.) $ S LifejAD&D 100% ❑ Basic Child(6 Mo.-19 Yrs.;23 Yrs.if full-time student)$ $ Dependent Life Higher age limits apply: In LA-21 Yrs;24 Yrs.if full-time student. In OK-to age 21, Employer Contribution for Dependent ❑ Optional or older if full-time student. Life q Dependent Life Optional Benefit Amount(describe): Note: Stand-alone benefits for Dependent Life, Child Life or AD&D are not available. Accident Plus is available only for the Employee with Basic AD&D. CLASS 1 EARNINGS DEFINITIONS - Complete Only for Salary Based Plan. In no event will salary exceed the amount shown in the Employer's payroll records,or for which premium has been paid(if less). © Earnings standardly include annual base salary,or annualized hourly pay(excluding overtime)and any commissions averaged over prior 12 Months. Earnings are determined on the last day worked. If any other compensation is to be included or an alternate definition is wanted,describe below: Also include: Instead base on: Bonuses averaged over 36 Months. ❑Each Employee's W-2 earnings for prior year. _Other(subject to Home Office Approval ❑Other(subject to Home Office Approval) _ CLASS4DESCRIPTION COVERAGES BENEFITS All Full-Time Public © Employee Basic Employee Basic Term Life Benefit Amount(select one): Life © Flat benefit amount$ 20, 000.00 Service Employees © Basic AD&D ❑Multiple of salary: ❑iX 112X 03X El Other ❑ Accident Plus' Subject to S Minimum and $ Maximum "Unavailable in OK Rounded to next higher$1,000 unless requested otherwise below. ❑Other ❑ Optional Life Dependent Life(may not exceed state limits): Basic Optional ❑ Optional AD&O Spouse(Coverage terminates at age 70) S S Child(14 Days-6 Mo.) S S Employer Contribution for Basic Child(6 Mo.- 19 Yrs.;23 Yrs.if full-time student)S $ Life(AD&D 100 % Basic 1: Bi Higher age limits apply: In LA-21 Yrs;24 Yrs.if full-time student. In OK-to age 21, Employer Contribution for Dependent Dependent Life or older if full-time student. Life % ❑ Optional Dependent Life Optional Benefit Amount(describe): Note: Stand-alone benefits for Dependent Life, Child Life or AD&D are not available. Accident Plus is available only for the Employee with Basic AD&D. CLASS 2 EARNINGS DEFINITIONS -Complete Only for Salary Based Plan. In no event will salary exceed the amount shown in the Employer's payroll records,or for which premium has been paid(if less). Must be the same for all classes if list billed. 9 Earnings standardly include annual base salary,or annualized hourly pay(excluding overtime)and any commissions averaged over prior 12 Months. Earnings are determined on the last day worked. If any other compensation is to be included or an alternate definition is wanted,describe below: Also include: Instead base on: ❑Bonuses averaged over 36 Months. ❑Each Employee's W-2 earnings for prior year. ❑Other(subject to Home Office Approval) ❑Other(subject to Home Office Approval) (Attach separate sheet for additional classes) GL2-Life Supp.02 (over) Jefferson Pilot Financial Insurance Company, Omaha, NE I Office Use Only-ID# f A. CLASSES FOR LIFE&AD&D INSURANCE LIFE&AD&D BENEFITS SUPPLEMENT CLASS$AESCRIPTION COVERAGES BENEFITS All Full-Time Fire- 9 Employee Employee Basic Term Life Benefit Amount(select one): Fi hters and Fire Basic Life 13 Flat benefit amount$ 40,000.00 9 9 Basic AD&D ❑Multiple of salary: ❑1 X ❑2X ❑3X ❑Other ❑ Accident Plus` Subject to$ Minimum and $ Maximum Lieutenants Rounded to next higher$1,000 unless requested otherwise below. 'Unavailable in OK ❑Other ❑ Optional Life Dependent Life(may not exceed state limits): Basic Optional ❑ Optional AD&D Spouse(Coverage terminates at age 70) $ $ Employer Contribution for Basic Child(14 Days 6 Mo.) $ $ Life)AD&D 100% ❑ Basic Child(6 Mo.-19 Yrs.;23 Yrs.if full-time student)$ $ Dependent Life Higher age limits apply: In LA-21 Yrs;24 Yrs.if full-time student. In OK-to age 21, Employer Contribution for Dependent ❑ Optional or older if full-time student. Life % Dependent Life Optional Benefit Amount(describe): Note: Stand-alone benefits for Dependent Life, Child Life or AD&D are not available. Accident Plus is available only for the Employee with Basic AD&D. CLASS 1 EARNINGS DEFINITIONS.Complete Only for Salary Based Plan. In no event will salary exceed the amount shown in the Employer's payroll records,or for which premium has been paid(if less). 9 Earnings standardly include annual base salary,or annualized hourly pay(excluding overtime)and any commissions averaged over prior 12 Months. Earnings are determined on the last day worked. If any other compensation is to be included or an alternate definition is wanted,describe below: Also include: Instead base on: Bonuses averaged over 36 Months.E Other(subject to Home Office Approval ❑Each Employee's W-2 earnings for prior year. ❑Other(subject to Home Office Approval) CLASS&DESCRIPTION COVERAGES BENEFITS All Full-Time 9 Employee Basic Employee Basic Term Life Benefit Amount(select one): Life 13 Flat benefit amount$ 30, 000.00 Clerical / Technical 9 Basic AD&D ❑Multiple of salary: ❑1X U 2X CI 3X El Other _ ❑ Accident Plus" Subject to$ Minimum and $ Maximum Employees 'Unavailable in OK Rounded to next higher$1,000 unless requested otherwise below. ❑Other p Optional Life Dependent Life(may not exceed state limits): Basic Optional ❑ Optional AD&D Spouse(Coverage terminates at age 70) $ $ Child(14 Days•6Mo.) $ $ Employer Contribution for Basic Child(6 Mo.-19 Yrs.;23 Yrs.if full-time student)$ $ Life/AD&D 100 1 Basic Higher age limits apply: In LA-21 Yrs;24 Yrs.if full-time student. In OK-to age 21, Employer Contribution for Dependent Dependent Life or older if full-time student. Life I [] Optional Dependent Life Optional Benefit Amount(describe): Note: Stand-alone benefits for Dependent Life, Child Life or AD&D are not available. Accident Plus is available only for the Employee with Basic AD&D. CLASS 2 EARNINGS DEFINITIONS-Complete Only for Salary Based Plan. In no event will salary exceed the amount shown in the Employer's payroll records,or for which premium has been paid(if less). Must be the same for all classes if list billed. 9 Earnings standardly include annual base salary,or annualized hourly pay(excluding overtime)and any commissions averaged over prior 12 Months. Earnings are determined on the last day worked. If any other compensation is to be included or an alternate definition is wanted,describe below: Also include: Instead base on: ❑Bonuses averaged over 36 Months. ❑Each Employee's W-2 earnings for prior year. ❑Other(subject to Home Office Approval) ❑Other(subject to Home Office Approval) (Attach separate sheet for additional classes) GL2-Life Supp.02 (over) B. PARTICIPATION Total Number of Eligible Employees 646 Number with Eligible Dependents Number to be insured for Life(AO&C 646 Number to elect Dependent Life C. AGE REDUCTIONS AND TERMINATIONS FOR ALL CLASSES 1. Age Reductions-Life and AD&D Benefits reduce 35%at age 65,another 25%of the original amount at 70,and another 15%of the original amount at 75;unless requested otherwise. 0 Other(Specify) 2. Termination- Life and AD&D Benefits standardlv terminate at retirement(recommended for compliance with age discrimination law):unless requested otherwise.0 Other(Specify) D. REPLACEMENT COVERAGE © Yes []No Will all or part of this plan supplement or replace similar Life and/or AD&D coverage? If Yes, provide details below and enclose a copy of each contract to be replaced or supplemented. If replacement,prior insurance credit will be provided. Prior Carrier Effective Date of Prior Plan Termination Date of Prior Plan Mutual of Omaha 03/01/00 03/01/03 REMARKS (Identify by section name and item number) FOR HOME OFFICE USE ONLY GL2-Life Supp.02