HomeMy WebLinkAboutAGMT - Standard Insurance Company (MEDEX Travel Assist Program) • IP
I ; i , ; ;;`9r`, 21250 fiawfhome Blvd., Suite 600, Torrance, CA 90503
r �°! ph 310.543.9995 fax 310543.9905
wwwzbdi.com
March 30, 2006
Andy Tse
Management Analyst
City of Seal Beach
211 8 Street
Seal Beach, CA 90740
RE: STANDARD INSURANCE COMPANY — GROUP NO. 217208
SEAL BEACH POLICE DEPARTMENT
RENEWAL EFFECTIVE JUNE 1, 2006
Dear Andy,
We received the Basic Life /Dependent Life renewal for the Seal Beach Police Department
effective June 1, 2006 from Standard Insurance Company. The Standard will hold the
current rates through May 31, 2007 at the level outlined below.
Basic Life $0.56 per $1000 of Benefit
Dependent Life $0.26 per member
With the City's approval, The Standard is adding MEDEX Travel Assist to the City's Basic
Life /Dependent Life policy at no additional cost. This program will help employees and their
household members whenever they travel more than 100 miles away from their house.
MEDEX is already included in the City's Basic Life plan available to general employees. We
have enclosed a brochure for your review. To add this service to the Seal Beach Police
Department plan, please complete and retum the enclosed amendment form. For your
convenience, we have included a return address envelope.
If you have any questions, please do not hesitate to contact me or Kristin.
Sincerely,
y a...1. era.;
Liesel J. Collins, CEBS
Account Manager
Enclosures
cc: Kristin Yokoyama, ABD
�s Vim.
License N^0D58513
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III • 0
Request for Group Insurance Amendment
Standard Insurance Company
900 SW Fifth Avenue
Portland, OR 97204 -1282
Employee Benefits Consultant: Amy Sulkowski
Employee Benefits Service Representative: Deborah Yaghoubi
Employee Benefits Sales and Service Office: Orange
Employer Name: Seal Beach Police Department
Group Number: 217208
As an authorized representative of the Employer, I request that Standard Insurance
Company ( "The Standard ") amend the above Employer's coverage under the Group
Policy to make the following change(s):
Add MEDEX Travel Assist Program to Life Policy at no cost
I request that the amendment become effective on 06/01/06. I understand that the
amendment will not become effective unless approved and issued by The Standard.
I request that the amendment be approved by The Standard subject to The Standard's
usual underwriting requirements, including, if applicable, Evidence of Insurability or a
Pre - existing Condition provision.
I understand that the amendment, if approved by The Standard, will be issued in the
policy language customarily used by The Standard.
I understand that any increase in Insurance for a Member who is not Actively At Work
all day on the Member's last regular work day before the scheduled effective date of the
amendment will be deferred until the first day after the Member completes one full day
of Active Work.
I request that the amendment, if approved and issued by The Standard, become
effective by its terms without any further acceptance by the Employer, and that a copy
of this Request for Group Insurance Amendment form be attached to and made a part
of the amendment.
Sign Name: CAL- Title: ri!i - Mg--
Authorized Re sentative
Print Name: Maw 7. Ty- Date: O /12 /oi#
Standard Online Amendment Request 3/17/2006 11:35 AM