Loading...
HomeMy WebLinkAboutR-2012-112 - Executed & Accepted Proposal to Provide Life Insurance at a Cost not to exceed $15,500.00 from Reliance Standard Insurance Company for FY 2012-2013 RESOLUTION NO. 2012-112 A RESOLUTION OF THE CITY COMMISSION OF THE CITY OF DANIA BEACH, FLORIDA, AUTHORIZING THE PROPER CITY OFFICIALS TO EXECUTE AND ACCEPT THE PROPOSAL TO PROVIDE BASIC LIFE INSURANCE TO ELIGIBLE EMPLOYEES AND RETIREES IN AT A COST NOT TO EXCEED $15,500.00 AND SUPPLEMENTAL COVERAGE OPTIONS TO ELIGIBLE EMPLOYEES FROM RELIANCE STANDARD INSURANCE COMPANY FOR FISCAL YEAR 2012-2013; PROVIDING FOR CONFLICTS; FURTHER, PROVIDING FOR AN EFFECTIVE DATE. BE IT RESOLVED BY THE CITY COMMISSION OF THE CITY OF DANIA BEACH,FLORIDA: Section 1. That the proper City officials are authorized to execute appropriate documents to accept the proposal of the Reliance Standard Insurance Company on behalf of the City of Dania Beach to provide basic life insurance to eligible employees and retirees at a cost not to exceed $15,500.00 and supplemental coverage options to eligible employees as specified in the documents attached to this Resolution and incorporated by this reference. Section 2. That funding for the cost of the City's life insurance program is planned and shall be charged to the Health Insurance Fund, Life Insurance account#501-1800-519-4560. Section 3. That all resolutions or parts of resolutions in conflict with this Resolution are repealed to the extent of such conflict. Section 4. That this Resolution shall be in force and take effect immediately upon its passage and adoption. PASSED AND ADOPTED ON August 28, 2012. ATTEST: LOUISE STILSON, CMC PATRICIA A. FLURY CITY CLERK MAYOR 5 xrpsrG APPROVED AS TO FORM AND CORRECTNESS: = 11� ,r� 4NU 11 1 TH S RO Al CITY ATT RNAYTED Reliance Standard Life PRELIMINARY APPLICATION FOR GROUP INSURANCE Insurance Company 1. Prospective Policyholder: C, ;`"A G T �jc t4`emu-��'('k.0 �r1 (Exact Legal Name) 2_ Federal Employer Identification Number: 3. Complete address: 10C ,.; . `:��Ec -, \vrt . (Street Address) (City and State) (County) (Zip Code) Executive Correspondent Title Phone Routine Correspondent 3O C 'F 32a Title •IL- ; i L t Phone qr - k- (r1%b 1 X 3ltTss Mailing Address(If different) 4. Nature of business:(If Association: purpose,when rmed) 5.The prospective policyholder is a .0_corporation,JZL paM ership,Ja proprietorship,�union, aassociation,Ljother(spec' ) �t 6. INDICATE AFFILIATES OF SU SIDIARIES TO BE COVEREg IF ANY: (include divisions only if all are not to be included) No. of Employees by Coverage Name and Location Nature of Nature of Relationship Business Life AD&D WI LTD VAR VAI VCI Other 7. POLICY TO BE ISSUED IN THE STATE OF:� 8. Requested Effective Date: 1� 1 1 (If other than state of Applicant's main oTce,explain in REMARKS) (Month) (Day) (Year) 9. COVERAGES APPLIED FOR:[Life,tAAD&D,aWl,aLTD,0-VAR,aVAI,D VCI,_[Qther 10. Is any group insurance now in force or currently being applied for on the Proposed Insureds?dyes_ono If yes, (A) Indicate in REMARKS: name of carrier,type of coverage;effective date; brief benefit description; eligibility;etc. (B)Provide prior experience, including premiums and incurred claims(or paid claims and claim reserves at start and end of period.) 11. Is it proposed to terminate or change any existing group insurance coverage?11yes gno If yes, indicate in REMARKS: name of carrier Vpe of coverage; and date of tefmination, or date and type of change. 12.Are all Proposed Insureds actively at work?14yes Qno If not, please list the following for employees not actively at work NAME DATE OF BIRTH LAST DAY WORKED FACE AMOUNT REASON FOR ABSENCE REMARKS: This Preliminary Application is subject to the acceptance and approval in writing by Reliance Standard Life Insurance Company at the Administrative Offices in Philadelphia, Pennsylvania; and nothing contained herein shall be binding upon said Company until this Preliminary Application is so approved. $ has been paid herewith. It will be applied towar the first premium due on the policy or policies if any be issued. Such issuance is subject to the:terms; conditions; limitations; and exceptions of the policy or policies if any be issued. Any person who knowingly and with intent to injure, defraud, or deceive any insurer file a statement •f claim or an application containing any false, incomplete,or misleading information is guilty o a fel in the thirgr degree. Name of Agent or BroKer of Record(print or type) Share by i rr Du i-(- % tho zed ig re (State License Number) (State License Number) f / tSCN�a�1v� (State License Number) (titlepr positio with plica t) To the best of my knowledge,does this insurance replace any Dated at (' OF SG K,� ��z�jt existing insurance? =Yes r-1 No Date KA1 Group Print ort pe name ooffBBrof kegs firm,if applicable, . Agency Office (authorized signature) (Title) LRS-8209-0111-FL MANO STRNDRRD Con rmadon of Plan In ormation (10+Lives) Full Legal Name of Group: Website Address: Tax ID#: C (exactlyas to be shown in contract with exact abbreviations, n or imtion •�oo°— Q Executive Contact Name: Routine Contact Name--aC g i w = Phone#: Fax#: Phone#: `jf�— �� �' ' ' Fax (' :Y�1 = 1 >, a• E-mail address: E-mail address: C6 d Location: • Main Other. Location: ' Main Other: E When did Company Operations begin? Month_ /Year___ _7 100+lives. Should we use Policy Anniversary as reporting date for 5500? vYes(standard) No,use Form completed by(print name): Employer j Broker • G.A./T.P.A. Other: Is other group coverage(s)in force with Reliance Standard?/(•: No • Yes-Reliance Standard Group#: • On-Lime List Billed (preferred method)(Employer maintains eligibility data on-lime,real time) Bill On-Line Self-Administered(Employer maintains eligibility data&reports volume,lives&premium totals on-line) Delivery paper List Billed <100 lives(Reliance maintains eligibility data,mails bills,changes sent to Reliance Standard) & Paper Self-Administered(Employer maintains eligibility data&reports volume,lives&premium totals via mail) Employee TPA billing: Name: Address: Eligibility Method: Please note that we need an up-to-date census listing so that we can accurately prepare your first bill. Premium • Check Wire Transfer/ACH Credit-You transfer fimds to Reliance Standard's bank account Payment Options: • ACH Debit(only available for on-line billing)-You authorize Reliance to deduct funds electronically from account Bills will go to each Correspondent as noted below. If more than three bill groups,please supply details on a separate page. 1st Bill Group: Billing Group Name(optional): I , c); J • Routine Correspondent listed on Preliminary Application OR Correspondent: CAA •� Title: Location: • Main • Other/Address Phone: Fax: Email: 2nd Bill Group: Billing Group Name(optional): _QL, � S Location: • Main • Other/Address Correspondent: Title: Phone: Fax: Email: 3rd Bill Group: Billing Group Name(optional): _ Location: • Main • Other/Address Correspondent: _ Title: _ Phone: Fax: Email: EFN-1278 with Checklist Page 2 of 5 2009 Employee Eligibility,Service Waiting Period&Earning Definitions (if different by coverage,please note) Please select an eligibility description either for all employees(Class 1 box)or for each class as appropriate: Note:All Classes standardly exclude temporary-or seasonal employees. ------- -- ------------ - -------------------- ------------------------------------------- # of Hours worked per week: Includes:Q All Employees ❑ Other Description: (le.,Officer,etc...) Class I '�1 Full-time hours: 1 F V OR❑Exempt ❑Union ❑Hourly ❑Non-Exempt❑Non-Union❑Salaried ❑ Part-time hours: (if eligible) # of Hours worked per week: Includes: ❑ Other Description: ❑Exempt ❑Union ❑Hourly Class 2 ( Full-time hours: L' ❑Non-Exempt❑Non-Union❑Salaried (le..,Officer) ❑ Part-time hours: (ifeligible) # of Hours worked per week: Includes: ❑ Other Descripton: i ! ( ❑Exempt ❑Union ❑Hourly Class 3 0. Full-time hours: `5 ❑Non-Exempt❑Non-Union❑Salaried (le., Officer) ❑ Part-time hours: (if eligible) Other: (Attach page listing other eligibility categories or classes, if applicable) Employee Service Waiting Period:(time employee must work before becoming eligible for insurance coverage)* n/a SR(Travel Acc.) • No service wait 30 D_� • 60 Days • 90 Days • 1 Month 3 Months - Other: *For present employees covered by prior plan on policy effective date),time employed is credited towards service wait Individual Effective Date: (coverage effective date once service waiting period is complete) (see page 2 for voluntary coverage options) r • On the Date S.W.P.is completed I'of the Month coinciding with or next following S.W.P. • Other: Class Specific Waiting Periods(if applicable): Class 1: Class 2: Class 3: Individual Termination Date: (see page 2 for voluntary coverage options) (,.' Employe-,Term.Date - 1#of Mo. or • Last Day of Mo. coinciding w/or following Term. Date • Other Reinstatement Date: (not applicable for voluntary life) Must employee returning from an approved leave of absence/lay-off re-satisfy Service Waiting Period? • No,if returning within 6 months(standard) (t,�Yes • Other: Benefit • P of Month: Age,Class&Earnings changes effective the V of month coinciding with or next following change date Change • The Date: Age, Class&Earnings changes effective on the date of change • Other: `t Date v Earnings Definition Applicable to Class(es)or Coverage(s): • All • Other: Earnings Only- "Earnings": basic salary,prior to any deductions to a- 401(k)/403(b)• Section 125 plan(s). (standard) Exchtding: commissions,overtime,bonuses or any other special compensation not received as basic salary. • Basic Earnings including- "Earnings": basic salary,prior to any deductions to a• 40 1(k)/403(b)• Section 125 plan(s). Including:- Bonuses • Commissions Overtime • Incentive Pay Averaged Over • 3 years(standard) 2 years • One Year(n/a for GL(Life),VAR(Vol.AD&D)or SR(Travel Accident). Averaging applies to: • All Employees - Salespeople • Commissioned Employees • Officers Other: • W2 Earnings prior to any deductions to a• 401(k)/403(b)• Section 125 plan(s). Including:• Bonuses - Concessions • Overtime • Incentive Pay Prior Year or Averaged over • 3 years(standard) • 2 years Averaging applies to: All Employees • Salespeople • Commissioned Employees • Officers Other: Please submit Bonus Formula Questionnaire for any definition(s)that includes bonuses. • Use Kl Earnings for Partners: • Prior Year or Averaged over: • 3 years(standard) • 2 years • Include S Corp wording: • Prior Year or Averaged over: • 3 years(standard) • 2 years EFN-1278 with Checklist Page 4 of 5 May,2009 Electronic,provided in Adobe PDF(standard)* 5 '/z X 8'/2 Booklets* 8'/X 11 Flat Certificates(no cover)* C CInclude: - Company Logo(Aif format—300 d.p.i) • Agent Name Other: CIO *Flat Certificates are the only option for Voluntary Lines(Life/STD/LTD&SR(Travel Accident). u Same for Entire Group,combine multiple coverages(if applicable)(standard) ram. *Note: there is a maximum of 2 coverages combined per booklet;coverages cannot be combined in certificates. by C V Class �• b Coverage by Affiliate • Policyholder's Routine Correspondent (standard) Broker - Other: Booklet mailing instructions for multiple locations,if applicable: c Mail to: Administration Kit will be mailed per above instructions unless otherwise noted. Include Summary Plan Description(SPD)in addition to standard ERISA wording? Yes • -'No, ,If yes,please provide: Uj ERISA plan number(s): Life STD LTD Plan Administrator: • Employer (standard) Union Maintaining Plan Other-Administrator Name&Address: CA P" a W How are Plan Records kept?: Calendar Year Fiscal Year Policy Year(Anniv.) Family Medical Leave Act Include FMLA coverage continuance provision?: Yes No (n/a for SR,STD,DBL,TDB&TDl) Disability Claim Check Issuance: •J laimant,copy Policyholder (standard) Claimant • Policyholder Information: W-21s(including Employer FICA match)are automatically produced at no additional cost for LTD. For STD(including DBL,TDB&TDI),W-2 preparation is an option(at an additional cost—see proposal details) (Cumulative Monthly Case Summaries are Who will prepare STD W-2's and make Employer FICA match: • Reliance Standard Employer automatically, distributed for all Claims Reports are mailed to the Routine Correspondent Please advise of other instructions. STD&LTD claims) STD Telephonic Claim Intake?:(50+lives) No Yes-will you supply eligibility feed? • No • Yes ASO STD Only: Full ASO• Claim Payor Assist• Rate: $ /employee Advice to Pay(ATP)• Fee per claim:$ Primary Broker Name(as shown on license) U,(L .�y14j Share% Full Address: . 0 Contactfor?s: r 9,�� i Phone-'1`jy /`— Fax: 5�1—S S—J ?8 E-mail: • • Individual individual SS#: DOB: • • Corporation Corporate Tax ID#: Information must match Broker Name(as shown on license) SS#: individual signing preliminary application Currently appointed with Reliance Standard in situs state? • No • Yes,Agent# (if available) for corporation: If no,please attach license copy. Our Licensing Dept.will provide appointment package for completion. Additional Broker Name(as shown on license) Share%: Please provide information as listed above for all additional brokers. (if applicable) • G.A. • T.P.A. Tax ID#: Agreement on file with Reliance Standard? • Yes • No Contact for questions: Phone: EFN-1278 with Checklist Pagc 5 of 5 May,2009 �I I REIIRNCE STRNARRN We Insurance Company Prepared For: City of Dania Beach t BinderINVOICE Effective Date 10-1-2012 LifWAD&D 172 $5,173,500 .23/.02 $1,284.37 Includes retirees **Supplemental Life 57 $4.060.000 Step Rates $1,102A5 i Total Premium Due $2,3 Z **Estimate from prior coverage FWO W09 Request Jw,Tax ©ho Fonn tD#his acne.wQarr�rztnt �nIfMTMoo M+01i i tasty lsrat3TirM send to IM WO, slwwnorryou►taoorrMrtw I�' :Life N 8uiir+Ms nlsrti�16 -o Fryed +M from elbow CMdc+pproodab bdXIcr 0, wnx_daeailiation: ❑M*Ak tipaote proprietor Q C Cwpm tlon ❑S Oorwetion ❑ PertisareiraD O TmWoOeste LWAm#obNIY owpoW.Erow to UK olowiftWon{ECG aorpoentlon.3-R caporegon.P--patttWWM P. lufiw Aedhlat f%x1d R,.1h L and apt ar wib no3 taegrsMfar'e rwn ;steel eddisw IbP N 2w1 Nifarw Stl*K;&ft I5oo c�r..rae..anazw�od. , PA IS= Ust;atroorsrit ftAW O hWW 0000M 9 Nwntbsr EMW yota TV1 In the agPwopi)Ste bon.TIheI TIN prwAdedmust:nrel live name gtvah on_lhe wwoe'line 8oetill a Onoirr0..10.0 16 amid backup tellhhoksrrrg For k cilviO lels.~0 Your*KW Securer res* ijM:However,for a -M -FFM tellen.t+otepoprisbr.or dMragalydsd errtay,see ttrPiert I ItMm+acdartsorh pilye 3.Forother aNMklen enHdiPA It b your a.4m ybr kfenNNrxdog nsxrtbar laib.if you do not Rave a numbir,.trw t w to goto TMI on pop 3. /hies.if tlte.account is in ind a titan ono nam*sae the~on page 4 fbrgukWkm on whose tdarragot111orriarrrrb�r number to eater. 3 6 0 R 8 3 7 6 a E1 0 lJhhrter psi of perjtxy,f that:.` 4. The number Shawn on Oft form is rrgr correct b gwrw kkrttiffeaidon mxrrbw(or 1 are►waling fora number to be b9ued 10 k and 2: I am not subject tc badarp VAtIojd&p because:W tam attempt-ftm backup witltwklbrg,cr"1#►aysnot bean notified by the lntarnol iitwenue 9eivice f vw l grn subj o to bookup wNt xOdfng as.a moult of a failure to report all Aerstet or d Wdwtds,or(r4 the fftS hed rrotitlad me that I am no lance►subod 116 backup wilt wkling,and i 3. l am a,U.S.~or attw U.S penal(**nod below). mow ltaft bore You must omw out itom 2 abate if you have been nofiNSd by the IRS last you wo+twrre d*awh[rrnt to bwkwp wtr#toi ng bocause you have failed to report ai intoneax and widwWs on your tax raturn.For real solate b oNara.item 2 does rwatappty_For nrortgage Interest Pow Mquislow or abandortrhrelk of aaa+ret}property,r—oet IN.rirh otaebt.corrhidtrffortrta an indtvktuat reU►irrtentelrMvwrAff' ,and quneraity.pay"onts other". interest pnd dMdwx*y.oU are not required to sign the oer ore,ttrat you must proiW* +ow coned TIN.$ae tt+e Insaurcoons on page 4. ttlnnrt+rot � Gwwaf hs wuotk 11S Node.H a:requesWaivea yiw a tone ether than,F6rM W-9 to ragwast, Secdon nafarerrces�to the interval Revenue Cade unless othenvlse y r nk;ttt use tits nseprasrtu's tos4n if R'le atJ4�lYn r alntNar to tttl;Fo1'm Wes. noMd. WhOlon eta UA vareat.For%d"to ptupoeee y6u,we PWPOSS of Fuffn considered a UA person if You are. A person who is required to file an information return with the IRS,muet •An individual who is a U.S.cRizan or U.&resident alien; dbtain your correct ZJilcptgrer is on number MN)to report,for •A partnership,cotpor slice,company,or aeeodation created or Axempkr,ktcarrra paid to you,-veal aeta(e rrwrtjiage intetest orDanizad in tthe lJrM1Sd States or under two tersls of the Urtltad 3tateA, I y*Pddt aoquet mm or ab rwaVWd of socur+ed:property..eowo tion .An estate O&W than a fbretgn ests".or of debt croon or Yaw nN a to art till •A dwooe ire trust{as Woled in PAgul Oww"Obon 3D I.7M-7): Use Form W-Q onlyif Wyatt eta a U.S.person a rSSkteru ' Meta,to provide your c•.w, TIN to tthspereoh i equesting R(!he rwftS for Qsrrbtss MI kv e.-faterahips tttaE oorlduRK•a tradaor requsabur)and.tivtren ap pRcsWe.to: book was'rn iha United 8tatsa aregoneraMyAx wsad to pMy is tax do any tareign po trom 'swti of income fnam Such btddn"L 4.Cw*Uhat the TIN you are giving iL ccr, (or you are waiting fora ftrgw,In certain can where a Fenn W-9 has tacit trees mcelved a number to be Iseesd), part"O"Alp is prod to prowrio-ow apts w is a*woo person. 2.CertMy that you are not eutW to baotwp withholding,or and pay the withholding has.7)hovoll e,if ytiu area US.0 i voi%#apt W,,a 3.Claim woonviAlm Gorr►backup willftldine If you are a'U.S.earernpt partnerina, partnini ip oarhilueting a tiarfe or bueirtaAe to tths United payee ff apPpabta;:you era also oertxyrrp tttd a.U S.peraar,your states.provide Form Ytr-9 .ttte parbaacafitp taeb4b3etr you►us, Nocalbl Awe of any Donna s*income Gom A t a track or bueineas statue and avold wfttholding on Yourehare of parta"bip fnaom& is not ettt*d-to#*wit#alotding fast err foreign perVWW Share of connected Inoom . Cot No.1023tX Form W-9 titev.12-2Ctt)