1994-04
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, . ~ a" Reliance Stan. Life
"I.I~ Insurance Company@
8
January 12, 1994
City of Clermont
1 Westgate
Clermont, FL 34716-0219
ATTENTION: Joseph E. Van Zile
RE:
PARTICIPANT: City of Clermont
VOLUNTARY TERM LIFE INSURANCE POLICY NUMBER: VG 2922
Dear Mr. Van Zile:
This letter will confirm the Administrative Agreement by and between Reliance Standard Life Insurance
Company (herein called the Company) and the above named Policyholder. This agreement takes effect on
December 15, 1993.
The terms of the agreement are as follows: An .Open Enrollment" will take place from December 15, 1993
to January 15, 1994.
During this time, eligible employees and their dependents may enroll for the insurance coverage provided
by this Policy. Applications for employee amounts of Insurance up to a total amount of $10,000 (under age
70) and dependent child amounts of insurance will not require proof of good health provided:
(1 )
the application is complete, signed and received by the Participant during the open
enrollment, and
(2)
the applicant was not previously declined for insurance coverage by Reliance Standard
Life Insurance Company, postponed or had their application withdrawn.
The insurance coverage will be effective on the date the application is signed, provided any applicable
service waiting period has been satisfied.
Applicants who previously applied and were declined by Reliance Standard Life Insurance Company or had
their application withdrawn or voluntarily terminated their insurance coverage with the Company, spouse
insurance coverage, all amounts for employees age 70 and over and any employee amounts over $10,000
(under age 70) are subject to proof of good health.
This agreement may be amended by mutual agreement between the Company and the Participant.
This agreement may be terminated by either party with 31 days advance notice to the other party.
This agreement is subject to the laws of the State of Rhode Island.
2501 Parkway, Philadelphia, Pennsylvania 19130-2499
(215) 787-4000
(800) 351-7500
City of Clermont
Jal)Uary 12, 1994
VG 2922
Page 2
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Exçept as stated herein, nothing contained in this agreement will alter or affect any of the terms of the
Policy.
RELIANCE STANDARD LIFE INSURANCE
COMPANY ~
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SIG ATURE
CITY OF CLERMONT
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SIGNATURE ---
Kriszta H Van Arsda1e
NAME
Assistant Secretary
TITLE
January 12, 1994
DATE
Robert A. Pool
NAME
M;:¡yor
TITLE
Fphrl1;:¡ry 1, 1994
DATE
.
8 PARTICIPATING UNIT APPLICATION8
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RELIANCE STANDARD LIFE INSURANCE COMPANY
HOME OFFICE: CHICAGO, ILLINOIS
ADMINISTRATIVE OFFICE: PHILADELPHIA, PENNSYLVANIA
Effective City of Clermont, December 1, 1993, (herein referred to as the Participating Unit), agrees to be a participant in the
ASL Group and Blanket Insurance Trust, and agrees to be bound by all the applicable terms and conditions of the Trust
Agreement.
The Participating Unit acknowledges receipt of a copy of the Trust Agreement and a copy of the Master Policy.
The Participating Unit agrees to make insurance available to its Eligible Persons in accordance with the terms and conditions
of the Master Policy Numbered VL 600 issued to the RSL Group and Blanket Insurance Trust.
1. NAME OF SUBSIDIARIES, DIVISIONS OR AFFILIATES: Not Applicable.
2. PARTICIPATING UNIT NUMBER:
VG 2922
3. PARTICIPATING UNIT ADDRESS: 1 Westgate
Clermont, FL 34716-0219
4. PARTICIPATING UNIT ANNIVERSARY DATE: January 1st in each year.
5. PREMIUM DUE DATE:
First of the month.
6. ELIGIBLE PERSONS:
All actively-at-work, Full-time employees of the Participating Unit, except any person employed on a temporary or
seasonal basis, and their Dependents. Employees who were not covered under the prior policy form # LAS 6383 as
of December 1, 1993 must complete 6 months of continuous employment prior to enrollment.
"Actively-at-Work" means: a person actually performing on a full time basis each and every duty pertaining to his/her
job in the place where and manner in which the job is normally performed. This includes approved time off such as
vacation, jury duty and funeral leave, but does not include time off as a result of injury or illness.
"Dependents" means:
a) the employee's legal spouse;
b) the employee's unmarried child(ren), including any foster child, adopted or step child who resides in the employee's
home and is age 14 days but under 20 years of age and is financially dependent on the employee for support; and
c) the employee's unmarried child(ren), including any foster child, adopted or step child who is attending a college
or other school on a full-time basis, and is financially dependent on the employee for support to age 26,
A person may not have coverage both as an employee and as a Dependent. Only one insured spouse may cover the
eligible children as insured Dependents. The employee or spouse must be insured in order for children to be insured,
Spouse Maximum Age: 75
LRS-8348-01-o592
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A1CIPATING UNIT APPLICATION (ContAd)
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On the date of application, the spouse must be under age 70.
"Full-time" means: working for the Participating Unit for a minimum of 30 hours during a person's regularly scheduled
work week.
7. BENEFIT AMOUNTS:
Each Eligible Employee and Spouse may select an amount of insurance (in increments of $10,000) for which
he/she is automatically eligible. The minimum amount of insurance coverage which may be elected Is $10,000 and the
maximum is $500,000, subject to age and evidence of insurability requirements, as applicable.
The Benefit Amount in effect on the Insured Person is subject to automatic reduction beginning at age 75 as shown in
the Table below. This reduction applies equally to those Insureds initiating insurance coverage at age 75 or over.
AGES
FACE AMOUNT REDUCES TO:
75-79
80-84
85-89
90-94
95-99
100 +
60.0% of available or in force amount at age 74
35.0% of available or in force amount at age 74
27.5% of available or in force amount at age 74
20.0% of available or in force amount at age 74
7.5% of available or in force amount at age 74
5.0% of available or in force amount at age 74
The amount of insurance on a Dependent Spouse automatically terminates at age 75.
The Amount of Insurance for each Eligible Dependent Child is as follows:
Attained Age
Amount of Insurance
0 but less than 14 days
14 days but less than 6 months
6 months to 26 years
None
$1,000.
$2,500., $5,000., $7,500. or $10,000.,
as elected on the individual application.
8. GUARANTEED ISSUE AMOUNT AND EFFECTIVE DATE OF COVERAGE
An Eligible Person must apply in writing for this insurance.
GUARANTEED ISSUE AMOUNT:
EMPLOYEE: If an Eligible Employee is under the age of 70 and applies for coverage within 31 days of becoming
eligible, up to $10,000 of insurance will be issued. The Employee's Effective Date of Coverage will be the date the
Application Is signed, provided any service waiting period has been satisfied and any premium has been paid, as
applicable.
DEPENDENT SPOUSE: All amounts on eligible Spouses are effective on the date the application is approved by
the Insurance Company.
LRS-8348-D1-D592
-1.2-
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&ICIPATING UNIT APPLICATION (Contac.)
'.
AMOUNTS OVER THE GUARANTEED ISSUE AMOUNT AND AMOUNTS APPLIED FOR AFTER THE INITIAL
ELIGIBILITY PERIOD:
An Eligible Person's Effective Date of Coverage will be the latter of:
1. the date the Eligible Person completes and signs the Application; or
2. the date the Application is approved by the Insurance Company and any additional premium is received.
Amounts of Insurance on Dependent children are effective on the date the Application is completed (provided the
employee has insurance coverage or the spouse has been approved for Insurance coverage).
Under all circumstances, premiums must be paid as required, and service waiting periods, if any, must be satisfied,
9. PREMIUMS:
Premiums, as shown on the attached rate page, are payable monthly, in advance. Premium increases, resulting from
an Insured or an insured Dependent entering into a higher age bracket occur on the Participating Unit anniversary date
coinciding with or next following such Eligible Person's last birthday.
10. MINIMUM PARTICIPATION REQUIREMENTS:
25 continuously approved employees
Such employees must be approved within 60 days of our receipt of this application.
This Application shall constitute the entire agreement between the parties which may not be altered or amended without the
written consent of both parties.
ACCEPTED BY:
RELIANCE STANDARD LIFE INSURANCE COMPANY
~,i.mJ" t~
Assistant Secretary
City of Clermont
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TITLE:
TITLE:
Mavor
DATE:
DATE:
February 1. 1994
LRS-8348-D1-D592
-1.3-
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MONTHLY PREMIUMS
PER $10,000
8
a
City of aermont
VG 2922
Effective Date December 1, 1993
These Rates Include Waiver of Premium
AGE
RATES
CHILDREN
less than 30
$ .94
$ .79, $1.19, $1.59 or $1.99
as determined by the age 6 months
to age 26 benefit option as elected
on the individual application.
30-34
1.16
35 - 39
1.59
40-44
2.20
14 days to
45-49
3.95
6 months
50-54
5.89
$1,000.00
55 - 59
8.24
60-64
12.96
6 months to
65-69
20.06
26 years
70 and over*
40.00
$2,500., $5,000., $7,500, or $10,000.
as elected on the individual
application.
*Note:
For Insureds age 75 and older, the above rates are equivalent to per $10,000.00 of coverage in effect prior to age
75.
Premiums are based on the Insured's age as of his/her last birthday.
Premium increase resulting when an Insured enters into a higher age bracket occur on the Participating Unit Anniversary
Date (shown in the Certificate) coinciding with or next following his/her last birthday.
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VOLUNTARY GROUP TERM LIFE INSURANCE LIVING BENEFIT RIDER
(THIS RIDER ADDS AN ACCELERATED BENEFIT PROVISION. RECEIPT OF THIS ACCELERATED BENEFIT WILL REDUCE
THE DEATH BENEFIT AND MAY BE TAXABLE. INSUREDS SHOULD SEEK ASSISTANCE FROM THEIR PERSONAL TAX
ADVISOR.)
Group Policy Number: VL 600; Participants Number: VG 2922
Issued to Group Policyholder: RSL Group And Blanket Insurance Trust; Participant: City of Clermont
Rider Effective Date: December 1, 1993
This Rider is attached to and made a part of the Policy indicated above. The Policy is hereby amended, in consideration
of the application for this coverage, by the addition of the following benefit. In this Rider, Reliance Standard Life Insurance
Company will be referred to as "we","us","our".
DEFINITIONS: This section gives the meaning of terms used in this Rider. The Definitions of the Policy and Certificate also
apply unless they conflict with Definitions given here.
"Certified" or "Certification" refers to a written statement. made by a Physician on a form provided by us, as to the Insured's
Terminal Illness.
"Death Benefit" means the insurance amount payable under the Policy at the death of the Insured, subject to all Policy
provisions dealing with changes in the amount of insurance and reductions or termination for age or retirement. It does not
include any amount that is only payable in the event of Accidental Death.
"Insured" means primary Insured, Spouse and Dependent Children, if applicable.
"Physician" means a duly licensed practitioner, acting within the scope of his license, who is recognized by the law of the
state in which diagnosis is received. The Physician may not be the Insured or a member of his immediate family.
"Policy" means the Group Life Insurance Policy issued to the Group Policyholder under which the Insured is covered.
"Terminally III" or 'Terminal Illness" refers to an Insured's illness or physical condition that is Certified by a Physician to
reasonably be expected to result in death in less than 12 months.
"Written Request" means a request made, in writing, by the Insured to us.
All pronouns include either gender unless the context indicates otherwise.
DESCRIPTION OF COVERAGE: This Benefit is payable to the Insured if, after having been covered under this Rider for
at least 60 days, an Insured is Certified as Terminally III. In order for this benefit to be paid:
(a) the Insured must make a Written Request; and
(b) we must receive from any assignee or irrevocable beneficiary their signed acknowledgement and
agreement to payment of this benefit.
We may, at our option, confirm the terminal diagnosis with a second medical exam performed at our own expense.
LRS-8596-001-{)690
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AMOUNT OF THE LIVING BENEFIT: The Uving Benefit will be an amount equal to 50% of the Death Benefit applicable
to the Insured under the Policy on the date of the Certification of Terminal Illness, subject to a maximum benefit of
$250,000.00. This benefit will be paid as a single lump sum or in installment payments mutually agreed to by us and the
Insured. The Living Benefit Is payable one time only for any Insured under this Rider.
EFFECT OF BENEFIT: If an Insured becomes eligible for, and elects to receive this benefit, it will have the following effects:
(a) The Death Benefit payable for such Insured will be reduced by an equal amount to the Living Benefit paid to such
Insured. The amount of the Living Benefit plus the corresponding Death Benefit will not exceed the amount that
would have been paid as the Death Benefit in the absence of this Rider.
(b) Any amount of insurance that would otherwise be continued under a Waiver of Premium provision will be reduced
proportionately, as will the maximum Face Amount available under the Conversion Privilege.
MISSTATEMENT OF AGE OR SEX: The Living Benefit will be adjusted to reflect the amount of benefit that would have
been purchased by the actual premium paid at the correct age and sex.
TERMINATION OF AN INDIVIDUAL'S COVERAGE UNDER THIS RIDER: The coverage of any insured under this Rider
will terminate on the first of the following:
(a) the date his coverage under the Policy terminates;
(b) the date of payment of the Living Benefit for his Terminal Illness; or
(c) the date he attains age 75.
ADDITIONAL PROVISIONS: This Rider takes effect on the Effective Date shown. It will terminate on the date the Group
Policy terminates. It is subject to all the terms of the Group Policy not inconsistent herewith.
In witness whereof, we have caused this Rider to be signed by our Secretary.
~CL ry~
ACCEPTED BY
CITY OF CLERMONT
Secretary
Signature of Officer: ~ ~ ~
Title: Mavor "-----
Date:
February 1, 1994
LRS-8596-D01-D690