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RESOLUTION NO. 94-96
A RESOLUTION OF THE CITY OF DANIA, FLORIDA,
ACCEPTING PROPOSAL OF ROYAL MACCABEES LIFE
INSURANCE COMPANY FOR CITY'S BASIC AND
SUPPLEMENTAL LIFE INSURANCE PLANS; AND
PROVIDING FOR AN EFFECTIVE DATE.
x�
BE IT RESOLVED BY THE CITY COMMISSION OF THE CITY OF DANIA
rr FLORIDA; ,
r 3 !Section 1. That that certain proposal of Royal Maccabees Life Insurance e '
Company for the City's Basic and Supplemental Life Insurance Plans, beginning pit
October 1, 1996, at a cost of.26 per$1,000 of coverage for Life; and .04 per$1,000 of bM
` coverage for AD&D, a copy of which is attached hereto and made a part hereof as
Exhibit "A", be and the same is hereby approved and the appropriate city officials are Y
�1•1 ! 1 ..� �'CI XI ..
hereby directed to execute same.
r a !
tion 2. That all resolutions or parts of resolutions in conflict herewith be and
the same are hereby repealed to the extent of such conflict.
vr�x= t r
x Section 3. That this resolution shall be in force and take effect immediately upon
A; its passage and adoption.
� s
PASSED AND ADOPTED THIS 24th DAY OF Septe r, 1996. '
YOR-COMMISSIONER "
1Cna ��i hZ t\ti,
ATTEST:
CITY CLE <-AUDITOR
APPROVED AS TO FORM AND CORRECTNESS: 4
!
itr s ��.nF n,
> ar dr
v
CITY ATTORNEY
Resolution No. 94-96
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^T A Nil rvt/ P �•
•S�'N ''�¢tiz�kvA�I J�'s
tk CITY► OF ► IA
AN
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r.
Proposers. . ach u
} Yr4y 9
t "`r fhtitf
the FRONT of the,. proposages propo�6.
Not
Group Basic
Supplemental Life
� I
Supplemental AD&D
Date 9/6/96
Proposer's Name/Address
Maccabees Life Ins. Co
Y ��Ct +J z �"•A�
7�1"�1Y.R��4�� h. �•,
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a ,ayah . .. • • . . .. x.'
Altamonte Springs, Fl. 32701
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1 • ••1 i
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Arthur L. Larmay
V �l+ Chi sII
} 6District ManagerA.
Wr rvr n4�, ac .
13
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for Y,f�1i'r• • '
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Prepared By:A. Louis rmay
Proposer: Royal Maccabees Lfe F, ',r .a 'K
r` Telephone: 40/-JJ9-49
r
800-715-4648
j BASIC TERM LIFE AND AD&D PLAN L Y POOLED � , r
s
City oL Dania M
w e
.s remium Summary Active and Ret ' d Emnlovees
fj 1 V
i Monthly
,. Coverage Nusmub ed Rate Per Monthly
�-- Volume 000 a —Tot
/Jr r M1 Lk
za ActiveLife yp 4t
AD&D � $5 350, 000 X 0.26 1,391.00 i
X1 Rj
� 'r+�. Retired
Life
' AD&D g--i 000 g (Step age rates apply) rkar r`,
R'
A Total Life and AD&D Monthly Cost 1, 705.00
Total Annual Cost (Monthly x 12 '
Q• 1• - Is assignment available? YES R No
r
Q• 2• - Is Waiver of Premium Included for X �
active employees? YES_ NO
?rr` fi
If no, may W.P. be added? YES_ NO m�� �`
At what additional premium?
r�ynt��YS
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/ Proposer: A. Louis Larmay Prepared By: Royal Maccabees Life
Telephone:_ am_aa4_4onn
800-715-4648y
BASIC LIFE AND AD&D INTERROGATORIES d�f '
City of Dania Q,
?"? k Vtgu Kyh Cd�y''
S
Interrogatory Answer
X.
' I. Is your proposal valid for 90 YES f� "
{ days from proposal return date? {, r �
2. Are rates guaranteed 12 months
from effective date? r ,
. '6'
P: (If guaranteed longer, showlength) . 24 months
3. What billing system do
,r ri
F o
(self-accounting or list bill) ? Either - your option sa,�
4. Does your proposal duplicate the YES
present Basic Life and AD&D program?
". If no, show all deviations on
page 19. _
S. Are your contract provisions YES trr
equivalent to the current policy
provisions? If no, show ally„��ra
deviations on page 19.
7
6. Is premium summary based on YES
volume of insurance specified k ,
on proposal forms? �tl
7. Does your plan duplicate the Royal Maccabees Waiver is for
present Waiver of Premium Lifetime if totally disabled +x'
benefit? If no, show deviations prior to age 60 n�wr3
on page 19. c
8. Will you accept current enrollment current acceptable iN�rA "
listing, or do you require new U"r ?
enrollment forms? Explain.
�C� T�� T�itl38t1
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px xy a�.a
N Y £ 1 •0..•p0.i
fa� td7il��t�i�Vs rni , �a'7 %�Y f a:45 .�-t,.�J % yy�� ' Y�*'^� 3•t"'"��� �`"r�f��'; ' � 1 t1
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9
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Proposer: A. Louis Larmay
Yr} 3i v"4si
'4r
Pre ared B Royal Maccabees Life ✓ 's�' "y P y.
Telephone:
P 407-339-4900
BASIC LIFE 800-715-4648 r" AND AD&D INTERROGATORIES - r �1'tfi``w
(Continued) � f,
Znterr_ o� tt �
Answer
' 9• What is the disposition of Royal Maccabees Obligation
aooroved waiver of premium claims
Upon termination of the master
K policy?
-= 10. What is the disposition of Royal Maccabees Obligation
w29n-d-i-ng waiver of premium claims
S' r
upon termination of the master ;���,�,policy? a.J Ag
rn` r+ tiy�__6}jJj!
r IY� s��NJ'
11. Will you waive actively at work Yes, but if policy cancells.
rule and accept any pendingor the same rule would apply rfsd �J�"
existing disabilities
Jf cove ace '
s not extended t RY under the orior ;ti
olic
�. � x3
12. Have you included the required
�i
A specimen policy? YES
x: 13 . Is your Life proposal free- Y
standing? YES
q. If no, on what
conditions or other coverages
is it contingent? f'n�p
' r�>• U}'nY{�.1
E' 14 . If contingent on any other NIA
coverages, what
premium credit has been allowed? -
1 °• n k
o- is
5. What the claim charge for $65.00
life insurance conversion upon
term'
ination of employment?
16. Will You
Y provide annual premium
and claims data on active and
retired employees separately? YES X
NO17.
Where is your Life and AD&D
claims payment facility .rit,lti ..JJy�
N �1 yili
located?
Southfield. Michigan
4�
k
16
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y�Rr� 4 r fir "tA' i
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' Proposer: Royal Maccabees Life
Prepared A. Louis Larmay '; ,:; ax N i
Telephohr G07_43q cones5 , ,•` t3
BASK LIFE AND ADSD INTERROGATORIES - (ContDO-7154648
I
s
Interrocato tR" r ,
Answer
N FI,
IY4t 18. What is your average turnaround
time for paying the following
claims once the correct "informa- „ ,>
tion has been filed
� com an with your
P Y r Rrx.
a) Death by natural causes 5 days
M b) Death by accidental means 1ays1
c) Waiver of premium a
5 days
19• Who will represent your company in
negotiations with the Employer? ;
�$ (Show name, title, location, and
telephone n umber) , A. Louis Larmay `
x
District anager
5
407-339_4900 ?
r 20. Date
you can deliver the first
draft of the:
a) Benefit booklets '
b) Contract
� within 10 days � 'F` 'yMRy
21• What is your companyls A.M.
rat n,
Ir
{' Best Rating? `
Rating size e�ss
11 Yt r.d r. 1995
Present A - Excellent (1996) b 9 w4
1994
i 1 t 'RAY'
.R F.. 1993 u
22. Do you require an initial deposit? YES X No
If yes, when and how much?
41y yy ,Y
1st month's premium
ea
a;N
lI
i 4 j,;Fl Div
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6P<,y;u,y.'K .�"""r�.X k Y�R3 arvS - � e li �,. T +` y"�{n y.�',S ��J� 1��Le1 �y •. K
qA'. ._ .,...._-_• �-�efie" `✓, 4>-r. - .. �� '' :.,"4a �f�iS..'v{F n�-. .v< .� ;,�"a�.
�' !'� �i1^1�„Y+ ..ki..�£'.. .y,`,`�}1 � e '�, t j � 4 �.t ra "b a'+4r�� y � •!` Y
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Proposer: Royal�? Y Maccabees Life'r Prepared By: A. Louis Larma
Telephone: Y
407-339-4900 pg2A
BASIC LIFE AND AD&D 800=715
ERRO -4648
Cont
GATORIES - e((continued)
` swe
+fix 23. Are renewal rates sensitive
and adjusted according to:
A. The experience
only? Of the Pool
No
B 7 pl YM tyt.S?
Ll The experience of
Plus the experience the Pool
group in of the °`54.I+s
proportion to its r 'N :
credibility? "'
Yes art
C.
C es in Chang the groups a,
u i'kdi aYa+`i�
demographics?
Yes rw, ;
Legal,
Services:
24. Leg Sere ,�.,f�*e•
A. In the event of litigation
involving a disputed claim, {
r,.
do you provide legal .�;_'�}'��, �
services? r i t
No
t ,
,� � "y,,rsm7�y
B. x 'f
Is this legal service included in your administrative cost?
eb
4 .
C. If yes
0
explain covered services
+d Mk ,wl Yp'r 1� ,klt k
�kj
25. Will you
provide annual premium Yes "and claims datadays
120 da s :iaR
renewal? Y before ;,r7 , w•��r
26. Is dependent life included? Yes If yes, describe underwriting
requirements and list rates:
$50,000ry,
Non-medical 1S% f Yfta ri'!1!!❑ + `y*4 �'�vt��
}
r.rF wl 4" 0. iY
18 ex
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Aft
Royal Maccabees Life
Proposer: P� A. Louis Larmay
repared By:
BASIC LIFE AND AD&D DEVIATIONS
F u y YSu\��C'\�sT� K .: �� wR Jrl (aX •'� r
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x
P A` M°uvLtw
City of Dania
All deviations
n
must
hx� k tto list deviationsacknowledgment
there are no deviations from the requested programs.
NONE THAT I COULD SEE
bi?
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A�4 f'�CyStib1 Y,�"T�jttAy �%j,
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4X'�Yl�StYUYf�fs
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4,
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19
1 L
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b Y
s � i
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�..s.� s'•�„ 'a-.-. �� yr «((.��.1 �.
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Prepared By: A. Louis Larmay �"i�+ k ;A I'�t� .
t PYoposer: Royal Maccabees Life
' Telephone: 407-339-4900
4
800-715-4648
' i.0
City of Dania
Premium x
s (See Enrollment t've ET"^1 ovegs On i
in Appendix A
A.
Combosite Rate St )= Emplo ee
Life (none) Spouse 7 e
Child(ren) "
a AD&D
B• Aae
(Per $10,000 for Life and ADO t'a
c,
Less than Age 30 f°, k, "
Life $1.40
$1.40 , ;+X I
IN
Ages 30 - 34 ---._-- --
' Life $1.50
" AD&D $1.50 $0.60
s, Ages 35 - 39 ------
Li
fe $1.80
AD&D $1.80
0.60
Ages 40 - 44
Life
AD&D
Ages 45 �0_ 60
Y
Life 49
AD&D $4�� $4. 0.60
Ages 50 - -- —�-�_ r
c 54 Tl 5-1
Life $6.40 `"^5
AD&Dr
$6.40
$0.60t r
Ages 55 - 59
Life
AD&D $10. $1— 10. 10 _ $0.60
Ages 60 - 64 -
Life $15.30 ------ —
' �--- $15.30
AD&D v Srr `ti
$0.60
Ages 65 - 69 — -------
Life $30.10 ------ }F`
$30.10
� $0.60
AD&D � ?
Ages 70 - 74
Life N/— N/A N/-- ^ , k
Ages 75 - 79
Life N/ - N/A N/ ' air y m
20 re
s
yp t't5'r i Y �
r J. t d_ 1'tY/' ti IF l
u �. � a n . . z C S+ � 1:, v �: e"Z'"'a^'>na l�rt"i� r �' "s ttiv •t�7e ^� d1
. . .. .. _.n . _iF'R;'.�c TTa:'�`'.' r. . . ` `f � •a-r. . ':�,. . {n'r�Yr "'..`,kh.•^V�}p+t.._ s.;c 4.n.nt.k �. _.•,r ,lh..._
v•
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Proposer: Royal Maccabees Life Prepared By: A. Louis LarmayH
r A& Telephone: 07-339-
3
800-715-
SUPPLEMENT.. ;.IFE AND AD&D INTERROGATORIES xa "
,3
City of Dania � F
4' Interrogator
L
Answer
1. Is your proposal valid for Yes
90 days from proposal return
date?
". Step Rates in 5 year age brackets
2. Are proposed rates guaranteed
+ 12 months from effective date?
Yesfi f
ii. 3 . Is assignment available?
4 . Is Waiver of Premium included? Yes
ur.
If no, can it be added?
+w�iANv +r'J
At what additional cost?
S. What minimum enrollment is 15%
required?
a) Composite Rate Plan:
Employee N/A Age rated Plan quoted ra +F
Spouse
Children) a "scuff
b) Age Rated Plan:
✓ i £, 5j
rF ��
'• Employee In 5 year age brackets
z
f:
Spouse
Child(ren) ' `
fey anti�'iS �i
a
6. What is the maximum coverage Employee Spouse/
per person: Children
A. Without evidence of $50,000 $5,000/$2,000
AA �,4w}STi
insurability?
B. With evidence of insurability? $250,000 C
7. If Waiver of Premium is included, ,
r what is the disposition of approvedM1��
waiver of premium claims ?
upon termination of the master
policy? Waiver of Premium is for17
r >,
i e ime 1 isa a prior
to age 60
21 }ro +?x
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r bff1y',b�Y✓M1 , i y l 1..,y L/.l k l' � �� 'C rq ,
f �'YgT+tyl�� y�.A.Vlthr��� � +5"c^ 'v�". '-� '�7�'LT,u`�l'�'..ib"4'w+x�`"a o � Y 6�-� E•Y
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p • wer tl `�
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Proposer:_Royal Maccabees Life
" Prepared By: A. Louis Larmay
Telephone:
PLEMENTAL AD&D INTERROGATOR.r c•LIFE AND 800-715-4648 'y
.
- (Continued)°
Interroaa_ tor„ ` °°'
tY nswe �
i B. What is the disposition of Royal
end ' waiver, of premium claims
w upon termination of the master
' ki4z Policy?
' r t
ds 9• Have you included the
specimen required Yes
Polic> s y?
10. Are your Supplemental Life and Yes '
% AD&D proposals freestanding
or are the
t.
x , ;+y contingent on other
coverages? Ex
:> Y plain
What is the claim charge for
a
conversion upon termination of — $65.00
employment? r-
"� Are renewal rates sensitive
rrm •,
e ° and adjusted according to:
T A. The e
,• +' only?xperience of the pool ------------
_
5
7 B. The
i ,< experience of the pool
Plus the experience of X the 4d,
f max, group in proportion to its credibility? x..
4 , y
C. Changes in the gro .s p X
u % l�demographics?
' •' yet /Lk y ^r
r 15. Where is your Life and AD&D � T
r
claims pa Southfield, Michigan
Payment facility located? sd'
a" 16. What is
4 _ time foryour average turnaround
pa in a e
Y g the following
W claims once the correct information
has been filed- with your company:
A. Death by natural causes 5 daus ='
B• Death by accidental means . r �
C. Waiver of premium ays r,
5 days
22 „ z
SN�.,��ry�n+s�Y�ri9•rx
1
1%
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:rk'�h}� f J F�•''v `�ST•'T x ^`J. .pTA
?� !?-ir'�@ � '� :.`,+.0 r '.,i R '.\ `,fit n'.•��S�'44m�+�y`'�' v ^ j.1 I
l •;yry_ �'tf,"���.( -t4 l ��� '. ....-. 4 h,i X4t 1/��Y,t�
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Proposer: Roval Ma ab a Life Prepared By: ALarmav
r^ Telephone:_ 407-339-4900 '
+ Supp, NTAL LIFE AND 800-715-4648 "
AD&D RR "t'L0.RIES
- (Continued)
Interrovat�
Answer .ti 17• Who will represent your company in
nm negotiations with the Employer: ,
' Name
Title A. Louis Larmay
Office Location District Manager
Telephone Number Altamonte SorinQs ci
32701
407-
Does this person have the
Yes and No
authority to make binding
decisions?
18 • Date you can deliver the first
draft of the:
A. Benefit Booklets
" . , B. contract 3 weeks
tl" 3 weeks '
3 " 19• What is your company,
s A.M. Bestrating?
1995 Present A =Excellent (1996 1
1994
as
1993
------------
{
r ,f 20• Do you require an initial deposit?
t
If yes, when and how much?
' � �e 1� Monrhs's Premium
21. What billing method do you use At(i.e. self- your option
ff
accounting or list bill) ?
e 22.
What administrative requirements
,Ya t r
Jl 1h�t
are expected of the Employer:
{{
a A. Plan Installation: Listing of names/d,o.b./
numbers and class o insurance sex/ social security e31�
F w•
xd kr
B• Payroll Deduction: List of employees/names/d o b a }°
social security nuil
mbers and amounts of insurance andsif/
y} a
they elect dependent coverage.
( at? t
' � ' e � .nt J y•
9' Ft 'hv R`N�,
23
$ �.,�eL�` .H}Y r,F� t n. r ;r. r'+ r a Jti,,. '.�gy`•�µ .°I
1
tt
wie 4 6>
hT J ly
i
X, )
,
S• I'
A Y
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a
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: "'J Proposer: Royal Maccabees Life
I` r Prepared By: A. Louis Larmay
Telephone:_ 4n7_44o_4onn
"f rSUPPLEMENTAL LIFE AND AD6D IN OGATORIES 800-715-4648
' - (Continued)
r r
Answer
23. Is dependent life o
included. Yes
12 yes, describe al underwriting l g requirements:
VV"lei` .CL 4�S �n
24. Will you waive actively at work
=x its 7 1� rule and accept any pending or
existing disabilities ! coverage
js not e�ctendPd �nde t e
_ for
o11e ? Yes but if olic is cancelled the same rule would apply
E w
------------
25. Does your proposal duplicate the $50,000 Non-medical maximum
present Supplemental Life and
AD&D program? If no, describe
deviations
on Page 26.
` 26. Are your contract provisions Yes
equivalent to the current y? x " M
If no policy?
, describe deviations on
', page 26.
27. Will you accept
5 p an enrollment list Enrollment List
x Fa bY,i!M or do you require new enrollment forms? Explain
nqp� r 28. Legal Services:
A. In the event of litigation
a '
involving a disputed claim, No
i 4
- r
do you provide legal services?
} tr , B. Is this legal service
included in your administrative cost?
� xib r6 l t`rCSG.
Ile, C. If yes, explain covered
f
services: :,
I
24
j 1
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9 t�hy(f p4uyyx."A.T„ip
'�g.'T . AµpWV I .
rwr
_. . ,.J't- :u !':'�. Y✓'...�'K4� '��� �' -n - Y .r' ti�� r11 r{ i � �: Jmvy?',`.:i i.e �.yti.
M �.w°a>�,�c �4Yr. ' ` ' � '��.fly,4'�✓1' + z'sa,
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Proposer: Royal Maccabees Life Prepared By: A. Louis Larmay
Telephone: 407-339-4900 -
800-715-4648
S�PL N'�'AIl' ' FE MD AD&D INTERROGATORI S
- (Continued)
ZntL : roa___ato nswe
29• A. Will you assist the Employer Yes
in the communication and
enrollment process at the
tir annual open enrollment?
y
B. Attach a sample of our Yes
< <� r communication materials?
4 fl�
C. Is the cost of communication No charge
t F S�yj
and enrollment activities R(including materials) included k 'j+ " '
proposal?
in your
r r a' S rci'S�d t,•.
If no, itemize additional `
cost:
{ 'i2l kA t4 p�
ti( T e
30. Will You
y provide annual premium + �
and claims data 120 days before
renewal? Yes
, titltllf�et
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� y ` Proposer: Royal Maccabees Life prepared By: A. Louis Larmay
,M1
Telephone: 407-339-4900
800=715-4648
` t
SUPPLEMENTAL LIFE AND ADh_ P:V ATIONS
' —
NIZ
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„
m� City of Dania
All deviations must be specifically described below. Failure
'wp to list deviations is an acknowledgment,;,,r t gment by the proposer that
...... � tti� there are no deviations from the requested programs.
Apo t9 000 non-med� al maximum
At ngp 60 t•n age 69 t20 000 non-medical maximum
Tnenranro tprmjnj t
3 yt es at age 70
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5 tiR i� h` i
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Proposer: Royal Maccabees Life ('.oared By: A. Louis Larmay
•I)hone: 407-339-4900y
w
800-715-4648
"i
5 BASIC AND SUPPLEMENTAL LIFE AND AD&D INSURANCE'
r-r
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PROPOSER'S REFERENCES
City of Dania
Yt� Z VS'�JeT�,f k
Name of Employer:
The City of Coral Gables
b
1 I
* Diana Rodriquez
Contact:
Telephone Number:
305-460-5608
}
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Number of Enrollees: 505
Length of Client
a�, N Relationship: 7/1/94
n" $ • Name of Employer: The City of Sunrise
J Contact: Kay Mitchell
954-572-2496 {Telephone Number:
{r Number of Enrollees: 805
t,e t4"." , }M1a h•
Length of Client a§,
F Relationship: 6/1/94 t
C z
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A �f
Name of Employer: City of Cocoa Beach
�,v a Y,• r v� 4
rl �aS ;, Contact: Elly Johnson
� „ y
Telephone Number: 954-783-4911
Number of Enrollees: 169
s o
Length of Client 3/1/84
Relationship:
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Proposer• M Life Prepared B P Y:_
arm^v e Telephone: 407-4q9
ROPO84181983 AC "WLEDGMENT 0-715-4648
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All proposers are to complete
this the specifications. Please check page ill" ornf Willc Not" for each
item. Any "Will Not" answers re quire full explanation in the space
rat^ provided or on the separate Deviations Page included in this
�� yYt section. Proposer agrees that absence of ent
ry below shall mean
full compliance; i.e. , "Will".
will
Peae Will get Ex lain. ) r1
Financial Rating
2 x
_ 8 ratin
Compliance with lay z
3 X_
Authorized Signature 3 t �y
Specimen Forms/Contracts -- :-
fir
Effective Date <Period 7 J; r,i eir44-i
Contract
S x rytl Mrf rl
- COleaiat(afle
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" Men•Warrenty of Specs S
.� ,jp] tI
. * ferred Busina --a S �— —S2e_Pa¢e 26
hw
t Named insured Endorsenen
" n • Sole Agent Endorsement 6 —� s
Reratinng Endorsement —Y
Feneinatian Endorsement
6 6
1j's f'
Claim Reporting End. x6
ProMbft(on of warranty 7 --
E
Caaplianea with all other x --
eand(tiaro in See. I
not listed above
a Propoaer's Warranty 29yt
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° Propose- Royal Maccabees Life
y=- Prepared By: A. Louie Larmay
Telephone: - -
PROPOSER'S WARRANTY
r VF t
BASIC AND SIIPPLEMENTAL LIFE AND AD&D
Da
City nia
The undersigned 'g person by his/her signature affixed hereon
r ! warrants that:
a) This Proposerls Warranty applies to:
'xS h(ceckmark coverages
g proposed)
dw) 1) Basic Life and AD&D
X r=
s 2) Supplemental Life and AD&D
z
b) He/she is an agent for the proposing company. r ,
C) He/she has been specifically authorized to offer a
contract in full compliance with all re
quirements
„ z and conditions as set forth in this underwriting
r3 °kk submission, other than those deviations noted in r .iti the proposal a
If this ,d proposal is accepted, the contract will be
issued in accordance with the complete proposal as
� K pp p
c approved by the Employer. The RFP and the
Mli. �r proposal, including all amendments thereto, shall
� +�z
��� be appended to and become an integral part of the
formal contract. In the event of a discrepancy
between the documents, the order of priority shall
be the RFP the proposal (as and if amended) , and
v� the formal contract. IT —
urFafi, Signet re of Company icer % .
m GY 9/6/96
Date
Note: Have you also attached the Acuired signed and
r notarized SWORN STATEMENT UNDER SECTION 287.133 (3) (a
FLORIDA STATUTES, ON PUBLIC ENTITY CRIMES? )
s
YES X
/ NO
Y
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29 „ v ,
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SWORN STATEMENT PURSUANT TO SECTION 287 w(3)(a).
FLORIDA XrAn=, ON PUBLIC ENHTY CRIMES
THIS FORM MUST BE SIGNED AND SWORN TO IN THE PRESENCE OF A NOTARY PUBLIC OR OTHER
r OFFICIAL AUTHORIZED TO ADMINISTER OATHS.
by 1 x L This sworn statement is submitted to
CITY OF DANIA
[print same of the puI mNb'I
y1 by A. Louis Larmay District Manager
d v ea ,a
for Isdl Hda bee snfi�e d tltle)
# fprint trims of entity submitting sworn statemmtl
" whose business address is 427 Whoopinrt Loop Suite 1811 Altamonte Srpings Fl. 32701
and (if applicable) its Federal Employer Identification Number(FEII>) is
entity
ter, (If the has so FEIN, include the Social Security Number of the individual signing this sworn statement)< � 2 I understand that a'public entity crime as defined in Paragraph Section 2g7M I
{ c a violation of ( )(B)y Sty, means
business with any state or federal law by a person with raped di and directly related to the transaction of
r dF xa lie entity car with as agency or political subdivision of any other state or of the United
Stues,including but sot limited to, any bid or contract for goods or services to be provided to any public entity or an agency Or Pal subdivision Of any other state or of the United States and ' .
anti
.'r
bribery, collusion, racketeering coospuary, or material misrepresentation. invahvig �' ��' theft,
3. I understand that 'convicted'Or•conviction' as defined in Paragraph 287.133 (1)(b), Florida Statutes,means a
' ; + finding of guilt or a conviction of a public entity crime, with or without an adjudication of guilt,in any federal '
or state trial court of record relating to charges brought by indictment or information after July 1, 1989, as a y�
result of a jury verdict, aonjury trial, or entry of a plea of guilty or nolo contenders.
4. I understand that an 'affiliate' as defined in Paragraph 297.133 1 a Florida Sin
P O( ).-- _fetes, means: ,i a ; L A Predecessor or successor of a person convicted of a public entity crime; or
2 An entity under the control of any natural person who is active in the management of the end and who has
been convicted of a � entity
been c, videoshareholders,public entity crime. The term 'affiliate" includes thou offs
employees,member and � directors, lute.executives, ,
ownership by one s agents who are naive in the management of an affiliate. The '
Person of shares m a metro
car income among W°8 interest in another person, or a pooling of equipment
z ng P�when not for fair market value under an arm's length agreement,shall be a prima fade
" case that One Person controls another s Person. A person who knowingly enters into a joint venture with a person 'who has been convicted of a Public entity crime in Florida d
an affiliate. P ty during the preceding 36 months shall be considered
S. I understand that a' "
c Pao'as defined in Paragraph 787.133 (1)(e), Florida �fatutee,mr�^c eny pin
or entity organized under the laws of any state or of the United States with the le �'.
binding contract and which bids or applies to bid on contracts for the provision of o �� to enter into a
P goods or services let by a
P��y� or which otherwise transacts or applies to transact business with a public entity. The term n ✓I
includes those officers, directors, yrecutives, partners, sharehold 'peso
active in them ors, employees, members, aad agents who aze
anagement of an entity.
'ai rrpnls --�i"
J i
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a art
30
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4
4
. /�Qy. ni'!t'1 err!`! ! t'`✓:, ' � _ . -tSS�,H.�a"'"a^astg,S�,i�'��'�}
e r�
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CITY OF DANIA
, Y
6. Based on information and belief, the statement which I have marked below,is true in relation to the entity
submitting this sworn statement. [Indiate which statement appika j
Neither the patity submitting this sworn statement,nor say of its ofiteers, directors, etteeutives,
shareholders, employee;members, or agents who are active in the management of the
of the entity has been charged with POP Convicted of a lie tyI nor, . affiliate
pub entity crime nest to Jul
9 Y 1, 1989.
710 B or
6116d rl, a this
mb members,
or agentsawemcni,h Ore active
mole Of a OffiCCra, direCtof;mccutives,
f r. �'o ..,..��ti employee;mem6er4 or agents who are active is tits '
management of the oatity,Oran a8iliate of
the entity hat been charged with and convicted of a public entity crime
wbsegtteat to July 1, 19139.-
1 The entity submitting this sworn atatcm
aharehaiders, to en4 or one or more of its officers,directors, execuuVes,Partners,
employees,ye5 members, or agents who are active in the management of the entity, or an mffwarp of
the entity has been charged with and convicted of a public entity crime subsequent to July 1, 1989. However,
r there has been a subsequent Proceeding before a Hearing Officer of the State of Florida, Division of
Administrative Hearings and the Final Order entered the H
public interest to place the entity sub Ong Ofiiar determined that it was not iO the
or the final Mier] misting this sworn statement on the convicted vendor fuL (Attach a copy
I UNDERSTAND THAT THE SUBMISSION OF THIS FORM TO THE CONTRACTING OFF!
pJ, PUBLIC ENTITY IDENTIFIED IN PARAGRAPH 1 O OFFICER FOR THE
(ONE) ABOVE IS FOR THAT PUBLIC ENTIT ONLY AND, t`P
(" THAT THIS FORM IS VALID THROUGH DECEMBER 31 OF THEY
CALENDAR YEAR IN WHICH 1T IS FILED.
I ALSO UNDERSTAND THAT I AM REQUIRED TO INFORM THE PUBLIC EN771Y PRIOR TO ENTERING WPO
A CONTRACT IN EXCESS OF THE THRESHOLD AMOUNT PROVIDED IN SECTION nun, nng pA
�'` ,A•, STA FOR CATEGORY TWO OF ANY CHOGE IN THE MFORMA77ON CONTAINED W THIS FORM. r
[algOitUR] ig
�1
Sworn to and subscribed before me this to .,w day of g B 19-?/,,
t*' Personally lmowO ti es
1rF}, OR Produced identification -
Notary Public - State off_
.4
My commission expires—�-
i
wF1 (Type of Identification) (Printed typed or stamped
eommissioaed name of notary public)
+ if
PATRICIA A. AHRENS
NOTARY ►ly Comm EXP. B-3-97
= auauc Bonded By Service Ins
OF F No. CC347094
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Royal 25800 Northwestern Highway
P.O. Box 2165
, r
Southfield, Michigan 48037-2165
Maccabees Life Insurance Company
(313)357-4800
PRELIMINARY APPLICATION FOR GROUP INSURANCE
r tt !r t�'v t"}Jy77S�
'iii'";+ ,A^ • NAME OF APPLICANT: City of Dania. Florida Phone: (954 ) 921 -8700
1rbti at s', ADDRESS: 100 West Dania Beach Boulevard Dania
rcuy�!Street! Btatel (Zip Code)
�Frr In}5 NAME AND ADDRESS OF EACH SUBSIDIARY OR AFFILIATE TO BE INCLUDED: AFF, SUB.
1) Name: All divisions of City Government
❑ ❑
Address:
^ " r e j lS1mrU (Ciry) !Stale! (Zip Cartel
2) Name: ❑ ❑
4
Address:
(sirmt)
lCiryl !Stale! !Zip Code)
Is there any location of the Applicant's business to be excluded? ❑ Yes N No
$l • If "Yes," describe:
COVERAGES REQUESTED
A 29 Life (Basic) Life (Supplemental) ;n AD&D 24 Hr. ❑ AD&D Non-Occ
® Dependent Life ❑ Weekly Disability ❑ Medical Conversion ❑ Other
f a iy
(Not available in CA) Not available in MN „r
4 ( )
t iefr'a OTHER INSURANCE i
Is there any other group life insurance:
(i) presently in force and to continue in force;
(ii) being applied for;
(iii) being issued at this time of application; or U
)fF �, rkr1 (iv) scheduled to o into force within 30 days of the Requested Effective Date?".IYx � ;Ili g Y q j
❑ Yes N No If "Yes," give details:
Br ( ` Is the insurance being applied intended to replace lid f any Y existing group insurance in force? IN Yes ❑ No a�
If "Yes," give name of insurer and termination date and attach copies of the other insurer's schedule of benefits:
Manulife Financial Termination Date9etebeH--Eggs SEp7r7n,pEYt o /916
t `451rPhr ei��R:. -i'
REQUESTED EFFECTIVE DATE: Month October Day 1st Year 1996
1,
LIFE DISABILITY BENEFIT
�
❑ Waiver of Premium terminating at age 65 ❑ No Waiver of Premium
❑ Waiver of Premium terminating at age 65 or termination of contract, whichever is earlier (not available in AZ, FL, GA,
MD, MN, NM, PA & WI) t1 1,
❑ PA Waiver Term at normal retirement age (age 70 maximum)
❑ FL 1 Year Extended Death Benefit I1 FL Waiver of Premium
} t}`,",'�"�.�' ❑ 1 Year Extended Death Benefit ❑ Other:
ynz i .Sl
Y fie 53 yA1�, 1'. Are there any employees who are not presently working at their jobs on an active full-time basis? X Yes ❑ No
4 a If "Yes," complete Attachment to Preliminary Application—Actively at Work Statement
fay 5 Gts, P
AGENT(S) OF RECORD
f'rt � L B Bryan&Company y'.
t and ,
shall be considered Agent(s) of Record and entitled to credit for this Application.
GA-3000-R4 (6/92)
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(f n.P`•fXA+''`V1`t R � ° ° { F 51 i v }"` �,�.�J-y ts
1_ .,i r.::_.,r. ,• _ - . ,e 1, 151?Y'- nw'.'L'�^h:Yn.Eu - e`n`•
Sir
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It is hereby understood and agreed that: **
1. Final premium rates will be determined on the basis of the actual composition of the group of persons who become insured
z>n'�i��x�' • on the date the Polity becomes effective. Incases involving evidence of insurability,final premium rates may vary depending
on the insurability status of the employee to be insured.
2. No insurance shall become effective until enrollment cards or a census listing are received and this application is approved
by the Company at its Home Office. If the initial deposit paid is at least equal to 85% of the first month's premium, and
if the application is approved by the Company at its Home Office,insurance under the terms of the Policy shall be effective
on the Requested Effective Date.Otherwise, insurance will become effective onlywhen a policy
p cy is delivered and accepted
ft € in writing; and in the interim, liability is limited to a return of the initial deposit. Any delay in refunding the initial deposit
t. paid will not create a contract of gre ip insurance or any liability on the part of the Company except for return of such amount.
e ti
3. Cashing of the initial deposit check by the Company does not constitute approval of the application.
x' { 4. If any insured is to pay any portion of the premium,the insurance will not be effective until the minimum required percentage
1 of eligible persons have applied for coverage hereunder.
,n z* 5. No person other than an authorized officer of the Company has the authority to:
ha n" a. Waive the answer to any question in this application,
4 b. Waive a condition of any Policy issued as a result of this application,
r ,q c. Waive any of the Company's rights or requirements with respect to this application,
} d. Modify this application; or,
K y e. Bind the Company by making any promise or representation. (Not Applicable in MO)
6. All necessary particulars concerning
4 a + g persons to be insured on or subsequent to the date of issue of the Policy and persons
t „rk, whose insurance is to be changed or discontinued shall be furnished monthly to the Company by the Applicant on forms
; provided for such purpose.
o, eke- ,- 7. The various Life Disability Benefits as indicated on this form have been explained completely and the selection has been
made by the Applicant with full knowledge of the limitations and/or restrictions associated with the benefit selected. {
` f 8. Any person whose amount o(coverage is subject to evidence of insurability shall be insured only for the non-medical portion
f' rx e until such time as such evidence is reviewed by the Company and such person is advised in writing about the Company's t
a - approval or disapproval y
9. Any eligible person will be insured hereunder according to the provisions of the policy contract unless if his eligibility for »coverage is the result of clerical error and/or misstatement of age. ' f r '
All answers made on this application are true and complete to the best of my knowledge and belief. I understand and agree r
Y s k!N that such statements and answers shall become a pan of any policy or policies which may ultimately be issued by the Company
and I understand that the Company intends to rely on this information in determining whether or not to issue said Policy. r '
Dated this 19 96
v 2 d of September at Dania. Florida
Witness: Applicant: Ci of Dania Florida
(icensrXl res ent agent where required by taw)
f
" Title: lot, lei �✓x . � �✓��� k
I have personally interviewed an Officer or authorized representative of this Applicant and am satisfied that all questions have 4v r:t1 been completely and accurately answered, and, except as noted below, I have no knowledge of a^
P g y person with a healthy ti + '
c+ impairment or other knowledge as to why this group is not an acceptable risk.
The Actively at Work requirements have been explained to the Applicant. The undersigned has no knowlege of any form of
r 1a, group coverage(s) that: 1) will be in force concurrently with the Plan being applied for; 2) is being issued to the Applicant at
this time; 3) is scheduled to go in force for the Applicant within thirty (30) days of the Requested Effective Date.
rW `
—, Remarks:
Signed
Dated September 23 1996 U f
(A or or Broker) 4
** The Ins u er s Proposal in response to the Applicant's Request For proposals (RFP) is &re , '
attached hereto and becomes an integral " +
k part of the policy, In the event of a
discrepancy between the Proposal and the policy, the order of control shall be the
1) Request for proposals,
Policy. — (2) the Insurer' Asir «t�
pp,ry{b� afx; exp4`nira
xk e4P" u
„ 4
y:
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I 5�" �b ly ey" ��` .,}+T r_✓ , ,� w i c 2,{ `+. T ,.,. " '�ttz,y.. 41�,l w,.„ 4 tf"v�`4
yr
S „ • i
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3 s nth
1\
" fy r+�'{ s^ BENEFIT SUMMARY
1� Yx Y^ VC'f�fgg
nary Policy No.
` �' 1) NAME OF APPLICANT: Ci of Dania, Florida
TYPE OF ORGANIZATION:
C a A ❑ Corporation ❑ Sole Proprietorship ❑ Trustee ❑ Partnership ❑ Association ❑ Union
r ya a
;fr� ? ❑ MET/Association IN Other: CityGovernment
f�pw fspwdy)
3J�N q f t TYPE OF INDUSTRY:
SIC NO.
Specific Nature of Applicant's Business CityGovernment
EMPLOYER IDENTIFICATION NUMBER: 39'6000 Sox.
(9-digit number assigned by IRS)
PREMIUMS WILL BE PAID: IN Monthly ❑ Quarterly ADVANCE PAYMENT: $ ! PO. rr0
` € 2) ELIGIBILITY:
1 t t IR Employees actively at work on a full-time basis working 35'
hours
per week,
Number of full time: `�,� ce, cL-e,
s
❑ Employees actively at work on a part-time basis working B hours per week. +'
Number of part time:
If Retired Employees are to he included—defined as: E1—/GI124E UA1D6n -t,/jF U S y
s T �E E7✓/AEG Sociar: SE-tuA?m� A?ETii1C'
Other. Elected Officials and Commissioners �r�„-j-• , ^,;
ELIGIBILITY OF RETIRED EMPLOYEES: x r F
Are employees who retired prior to the effective date of this policy to be covered? 0 Yes ❑ No
If"Yes,"show coverage(Li
feAD&D)available as a separate Benefit Class under Schedule of Benefits Requested.
Are employees who retire on or after the effective date to be covered? M Yes ❑ No
F
If"Yes," show coverage (Life
��we AD&D) as a separate Benefit Class also. <;
$t t
EMPLOYEES NOT ELIGIBLE:
R,
43� r
K q�,fir ro" rR ' I@ Part Time q Temporary ❑ Retirees 18 Seasonal ❑ N/A ❑ Other: 'r�+
Total Number of Employees Total Number Eligible I�,
i
Number of Employees Being Covered
o
^tF z
� u z,�4w � at vtd
41 VJ.F�{•j, 34"��
4Fr M 1
j1.j\(p Rr
Y!�"vMw4�ni0.1.`
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i NP. � fh lam.
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3) WAITING PERIOD:
fri�t drisY "�,V'�he �r
Present Employees must have completed: _ Days Months
FigCURKer7r
El Other: Y t_7VKctl.E9. Co✓et.46-F /J' /nrinE�iFf� r
A`
or NOT CN/j/l.QyTZY E7UROLCEZJr F//tSl Q� ~7W PoLIOW nJG �O P
�Ry E>irp[oy,�c�/T,
g of
NI First of the month coincident with or next following completion
44K � iri
P 22 Day. Months (circle one)
Future Employees must complete: _ Days Months
❑ Other:
y Yvr.�4 rr �
1 fF5 tf� :y`7 ,
or ;
first of the month coincident with or next following completion of 3o Day onths (circle one)
4) EFFECTIVE DATE OF CHANGES (Increases/Decreases/Other):
u
i'ra : r O Date of Change RPremium Due Date following change Policy Anniversary following change
❑ Other:
EFFECTIVE DATE OF REDUCTIONS:
' r n
17 Date of Change Premium Due Date following change ❑ Other:
5) REDUCTIONS:
Life and AD&D 50%
�t#'�c�',� will be reduced b V --% at age 70 to a maximum of $25,000
and will be further reduced b '?
f Y 25�% of the remaining amount at age 75 to a maximum of $_10,000
❑ Other: is 1
REDUCTIONS FOR RETIRED EMPLOYEES
A. Retired on or after the Requested Effective Date:
Same as stated for active employees MlNrgskns CD✓t7�� r
Soo 0
❑ Other: '
y3y r� 5}v S. Employees who retired prior to the Requested Effective Date:
it t bD Same as for employees who retire on or after the Requested Effective Date of this policy.Mr,Vrm kM fES000 ;
"rf ❑ The Iasi amount the employee was insured for under the previous carrier. r
`x4 Attach a listing showing each employee's name and amount of insurance. 'P
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❑ Other: �
CONTRIBUTIONS a :.
9 i
Employee Contributions are Required: C9 Yes ❑ No
ril !rs y.v If "Yes," stale employee % 100
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Required for: _Supplemental and Deeendent Life
�r'1"tf`r)•'�
to he paid by Applicant
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t ¢; �F Note: Applicant must contribute no less than 25% of the total cost of benefits requested (except Alabama).
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6) SCHEDULE OF BENEFITS REQUESTED
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Weekly Disability Income Benefits
y v Benefit Life AD&D D
Class Dependent Life _% to a Elim. Period
Amount Amount Spouse Children Maximum of Acc. Srk TO Day Duration
Hap.
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Same Benefit Schedule Previous
In Eff t Wi h Man life Nor h er
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Include Accidental Dealh and Dismemberment Alcohol Exclusion?
Yes C No
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24uF If employees or class are engaged in sales, are commissions or bonuses to be included in the definition of BWE or BAE? fi
C Yes I' No If "Yes,""
, explain in "Additional Information Section"7) WEEKLY DISABILITY BENEFIT: #14
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r Y ? a r> Maternity Benefits: ❑ No ❑ 6 Weeks ❑ Same as any other disability
Occupational Coverage: ❑ No
p g ❑ Offset ❑ Other:
4 t; • Benefit Week: ❑ 5 Day ❑ 7 Day
z 8) DEPENDENT LIFE INSURANCE BENEFIT: H
Child: ❑ 14 Days to 19 Years IN Birth to 19 Years ❑ None
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Full-Time Student Extension: t31 19 to 23 Years ❑ 19 to 25 Years
❑ None
s
v zip ADDITIONAL INFORMATION: n
Application is intended to reflect all terms and conditions of Royal Maccabees proposal dated 9/5/96 to City of Dania's
RFP for Basic and Supplemental Life and Accidental Death and Dismemberment Insurance issued in August 1996,
including letters from Royal Maccabees dated September 17th, 18th and 191h. (Copies of Response and Letters Attached).
In the event of a discrepancy
PO Icy, between the Proposal, and amendments thereto and the x ,
y, the order of control shall be 1
and then 3) the Policy, ) the Applicant's RFp, 2) the Proposal as amended,
Monica Griffith RiskManager/Dania
Completed By: ,
Date: 9/27/96 ,
Applicant Interviewer. Lon Bryan/L B ervan&Comoan Y
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Royal 25800 Northwestern Highway
P.O.Box 2165
® Maccabees Life Insurance Company Southfield, Michigan 48037.2165
(810)357.4600
ATTACHMENT TO PRELIMINARY APPLICATION
ACTIVELY AT WORK STATEMENT
S NAME OF APPLICANT: City of Dania Florida
S In connection with the Preliminary Application for Group Insurance, the undersigned declares that all eligible employees who
enrolled'on or before the Requested Effective Date were Actively at Work on a Full-Time Basis on that date except those whose
names are shown below.
Actively at Work on a Full-Time Basis means actually working for the Applicant at least thirty (30) hours a week, performing
M ? all of the normal duties of the individual's job at the Applicant's normal place of business or other location, other than his
i p residence, where the Applicant's business requires him to be.
i,
^ ; It is understood that an employee not Actively at Work on the Requested Effective Date will not become covered until the
completion of one work day after the employee has returned to active work on a full-time basis.
When the employer pays the entire cost of employee coverage(s), eligible employees who have not had the
to complete an enrollment card will,nevertheless, be covered on the Requested Effective Date of the group plan PPa actively
P
!' at work on that date. However, if the employees contribute a part of the cost of employee and/or dependent coverage(s),
they must enroll before the contributory coverage can become effective.
{ , **Actively work requirement waived for currently enrolled if coverage not extended by
prior carrier.
er. �
Name of Date i
Absent Last Reason Date of Insured by Former
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Employee Worked for Expected Carrier? (Yes or No)
Absence Return Employee Dependent
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F Dated this .27 day of September
1996 , at Dania Florida
r; Witness Applicant: Ci!y of Dania
(lfc nsec/ sident agent where required by law) / J
By: �s r r
GA/B 3000 (2/94) TiTitle: _✓Gt.�-�"c �1U Qua�i fe,
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