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HomeMy WebLinkAboutContracts & Agreements_58-2009_CCv0001.pdf 10 Compensation Firranct l Mailing.Address_ Principal Life Disclosure Group Cies Moines, lA 5 1392-0002 Insurance Company I Addendum As a result of this sale, the broker may receive commissions, administrative service fees, other compensation including non-cash compensations and bonuses based on factors such as total premium volume and persistency or profitability of the business. The cost of this compensation may be directly or indirectly reflected in the premium or fee for the product(s) you have applied for on the attached employer application form. This compensation is in addition to any compensation the broker may receive from you. Contact the broker for further details: GP 54189.1 Page t of 1 07/2006 • .: 210 � rruiu! Mailing Address. Principal fife Employer Application for Group des Cvltiines» IA 5t} � �t}Gtl �insurance Company I Group Insurance GA California law prohibits an HIV test from being required or used by health insurance companies as a condition of obtaining health insurance coverage This form is for: new case amendment Account number Requested effective date:; May .1,_v `009 Advance premium received Employer Information Legal name of company(include dba) City of -Redil,ands El C-corporation El S-corporation El limited liability company El partnership D sale proprietorship other Government Agency Physical address(street? State Mate _--- ZIP code 35 Caion Street !Redlands CA 192373 fvtairing address(P.o.box) City State ZIP code P.O. Pox 3005 �ked'ands CA. 95373 -505 Contact Telephone number FAX number E-mail address Jaime Gc chenour �09) 795-751 (90 9) 335-47&2 jgochenodr=�)cit ofredi°and ,oro Nature of business SIC code Federal tax ID number Number of years in business Municipal Government � � 121 Have you been insured by Principal Life Insurance Company previously' El no ® yes If yes, when and under what name? through 12/31/2008 / Same Name Has the company been denied credit within the past two years, ever filed for bankruptcy, or is the firm now in the process of(or considering)filing for bankruptcy? In/ no El yes (attach an explanation) Complete the following if this coverage replaces other group insurance. Provide a copy of the most recent billing. Nate. Include prior carrier'informtion for past three yearse Name of Carrier Coverage(s) Effective Gate Termination pate SunLife enta? 1/1/09 4/30/09 Principal Dental 12/'31/09 Employers with Participating Tits Are employees of any associated business organizations(e.g, parent-subsidiary, brother-sister relationships,affiliated groups,etc,)to be covered? 21no El yes If yes, please list the affiliate or subsidiary below. Participating unit is an entity that is an affiliate or subsidiary related to the employer through common control or ownership.— Unit rfamer'addressifederat tax tll . a Nature of business Y Relationship to company Number of employees El include unit , 1. El-exclude unit r © include unit . _ El exclude unit Request for Benefits vision El short terra disability 0 long term disability El basic term life Options: El basic terra accidental death and dismemberment El dependent term life voluntary term life Options. 0 accidental death and dismemberment ❑ accelerated death benefits GP 45599-5 Page 1 of 6 09/2007 Request for Benefits(continued) 210 dental If you ars offering multiple dental benefit captions to employees, attach a list of which benefit options each employee elects, medical.- Do you want insurance for El employees employees and dependents PPO number(s)/name(s) If multiple,PPOs are elected, please include a list showing which employees are utilizing each PPCA. network choice. Attach list of which network each employee elects, benefit choice.Attach list of which benefit each employee elects, Medical plan number(s) m RX plan number Illustrated in proposal number 'Version number' Wanting Period/Effective Date Provisions Currently eligible Waiting Period (employees working the month g days Q days required number of hours on Y y 3 months 90 days or before the effective date El 6 months Fv1 other mate of Hire of new case/new coverage Note: If you wish all employees to have the same waiting period, the waiting period for with Principal Life): currently eligible should be marked the same as futures. Employees who have already met the waiting period above do not have to meet it again if continuously working. Futures (employees hired Waiting Period the day after the effective ❑1 month El 30 days g days months �90 days date of coverageor later):. Y -d months Z other Fate of Hj.re Employees will be day immediately following the final flay of the waiting period or change. Termination of eligible/terminate coverage will be on the last day employee worked or was part of an eligible class. on the: 21first day of the insurance month coinciding with or next following the final day of the waiting period or change. Termination of coverage will be the last day of the insurance month in which the employee worked or was part of an eligible class. Employer Contribution Complete this table listing the percentage of premium the employer will pay for each employee. - .. _ r Short term I Long term ! disability disability Voluntary Y Imo, Vision Basic term lifeterm life _« life e dical Dental 5 _ .� Employee 0/, 1 ° % % % °r I r °h ' _ _ Dependent ala IIIA hl(A :% i _.. w_wt°!c i % 100% 'Retired % NIAi N/A °/s % "/o % .. Note: retired coverage not available for all coverages. *If employees contribute to the coast of STD or LTD insurance,are these contributions made on a El pre-tax or El post-tax basis* Definition of Compensation(Life, STD, LTD) base wage(excludes:bonus, commission, overtime, etc,) -2(I year average) base wage(with bonus) ❑ W- (2 year average) [I base wade(with commission) ❑ W-2 (3 year average) base wage(with commission and bonus) contract salary [- otherGP 45699-5` Page 2 of 6 0912007 Deftinitionlof COirripimsation(Life, 'T ,LTD),(co tin ed) Should to definition differ by class? ] no Q yes,,explain When will salary information be updated? date of change El annually on the following date. 0 policy anniversary Q ether EmployeeEligibility Eligible Employees 21 n employee must work at lest 30 hours per week to be eligible for insurance.. other (if agreed to by the home mice of Principal Life) Ineligible`Employees An independent contractor(unless required by law) An employee who works less than the required number of hours per week, or is employed as a temporary or seasonal employee„ i Dental 210 If dental insurance is requested,do you want to insure retirees? El no � yes If yes, Z your current retirees 21 your future retirees If you are replacing dental insurance,did your prior dental coverage include benefits for orthodontia treatment? El no R yes Medical Do you offer medical coverage to your employees through another carrier(do not include information about insurance coverage that is being replaced)? El no n yes, number covered? TEFRA eligibility is defined as employers who employed 20 or more full or part-time employees for 20 or more calendar weeks in the current or preceding year, If this requirement is met, the group is TEFRA eligible and Principal Life will pay primary to Medicare, Do you meet the eligibility definition? El no El yes Is any employee presently not performing his/her duties on a full time basis due to an illness or injury? El no 11 yes If yes, explain: If you are a group with 51 or more employees requesting medical insurance, do you want insurance for retirees? n no 11 yes If yes, 0 your current retirees El your future retirees Medical/Dental[Vision COBRA eligibility is defined as employers who employed 20 or more full or part-time employees on at least 50% of the working days in the prior calendar year. Do you meet the eligibility definition? E] no Z yes If COBRA applies, please select desired billing option: F1 group bill policyholder 21 direct bill continuee(individual) If you currently have anyone on COBRA, please submit enrollment form with qualifying event date noted. All Ctearera its Employer elects to be: nle standard accounting El self accounting (not available for medical coverage) ERISA plan number: N/A Coverage: ERISA plan number: N/A Coverage: If more, attach list with ERISA plan number and coverage. Plan administrator: N/A Plan sponsor: TIT/A Agent for legal services:N/A----------- Ending date of plan's fiscal year: The Empioyee Retirement Income Security Act of 1974 (ERISA) requires that each employee benefit plan subject to the Act designate a"Named Fiduciary who shall have authority to control and manage the operation and administration of the plan." If this plan is subject to ERISA and the Named Fiduciary is other than the employer, fill in the information below. Principal Life may not be designated as Named Fiduciary. The"Named Fiduciary„shall be: N/A Designation as Named Fiduciary is accepted. (Required only if the "Named Fiduciary"is an Individual,) By Title GP 45699-5 Page 4 of 5 09/2007 Agreement and Signatures 210 It is understood that Principal Life shall not be responsible for any tax or legal aspects of the plan; The employer assumes responsibility for these matters, The employer acknowledges that they have counseled to the extent necessary with selected legal and tax advisors. The obligations of Principal Life shall be governed solely by the provisions of its contracts and policies. Principal Life shall not be required to look into any action taken by the named fiduciary or the employer and shall be fully protected in taking, permitting, or omitting any action on the basis of the employer's actions. Principal Life shall incur no liability or responsibility for carrying out actions as directed by the named fiduciary or the employer. It is further understood that by signing this application, the employer is purchasing insurance and not making an investment. No reserves, undeclared or unpaid experience premium refunds, or interest with respect to claim payments, nor claim proceeds themselves shall be considered plan assets under ERISA. The employer has been informed of the eligibility requirements'. The employer agrees that insurance applied for shall not become effective or remain effective unless the employer: a) is actively engaged in business for profit within the meaning of the Internal Revenue Code, or is established as a legitimate nonprofit corporation within the meaning of the Internal Revenue Code,- and b)meets the participation and contribution requirements. The employer agrees that insurance applied for shall not became effective unless the application and any attached page(s)are received, accepted and approved by Principal Life. If this application is accepted, all group policies will be combined and treated as one policy for the purpose of determining any experience premium refund. ■ The preexisting condition restrictions for medical and long term disability insurance have been explained to and understood by the employer. Actively at work and period of limited activity for life coverage have been explained to and understood by the employer; The employer understands receipt and deposit of advanced payment is not a guarantee of coverage. If a policy is issued from this application and is accepted by the proposed policyholder, we will apply the premium deposit to the first premium due for such policy. If no policy is put into force, the premium deposit will be refunded. Premium payment will be monthly unless otherwise indicated. Acceptance by the employer of any policy or policies issued with this application shall constitute approval of any corrections, additions, or changes specified in the space "For Principal Life Use Only" or as otherwise indicated can this application. Your agent or broker cannot change or waive any provision of this application or the policy or policies without the written approval of an officer of Principal Life in the home office. • The employer acknowledges and understands that if this application is approved, the group policy will determine all rights and benefits. • The person signing this form for the employer has legal authority to bind the employer for whom application is being made. • The employer agrees to make timely notification of any employee termination, status change, or other material changes that may affect the eligibility of employees or their dependents. Timely notification is no more than 31 days past the actual dateofsuch change. • The employer understands,'that failure to pay premium when due will be considered'a default in premium payment and coverage will terminate at the end of the grace period, if coverage is terminated for nonpayment of premium,, premium through the grace period is due and will be collected, The employer understands that coverage may also be terminated for other reasons as provided in the group policy. • The employer understands their rights and responsibilities if electing self accounting status. NOTE: If Principal; Life determines, due to requirements of law or because of our own underwriting criteria, to issue our group insurance through a multiple-employer group insurance trust, the employer hereby subscribes to and agrees to the terms of that trust: GP 45699_ Page 5 of 6 09/2007 Agreement and Signatures(continued) 210' Any person who, vVith intent to defraud or knowing that he or she is,facilitating a fraud against ars insurer„ subm,U, an application or files a claire containing a false or doe tive statement, may be gulity of insurance fraud. Fraud or misrepresentation may be grounds for nonrenewal or termination under the terms of group Policy, City of Redlands L rye P Cit erg Pa.t Gilbreath �= � � ,���4. Mayor Pro Tear 4-211-09 lctazt r €oi at�t{liriar3cfa 3} Ars�i'�li� ss r�acrr Cam sktr AjO Carel F'al trup SISI 0351162 14/1q/09 �Ig Lwe Of soft as"ti (if M&o than ore,aii,must sigt'T' For Principal Ufd uae Only GP 456914-5 Page 6 of 6 0912007 i. 'rhe plan is based on a complete inventory of the City's street trees, including the creation of a data base that delineates the species of every tree by location address and notes the locations of vacant sites suitable f'or planting street trees, I The Street Tree Plantino Plan includes recommendations for approved street tree species by location, taking into account the presence of overhead utilities and space planting widths, 3Street tree species have been selected on the basis of several criteria, including but not limited to the longevity and hath of the tree, species in()or area, appropriateness of the, tree to the space, minimal maintenance, adaptability to local soil conditions, hardiness to insect infestations and disease and root systems that, do not, buckle sidewalks or enter sewer lines. 4, The Street Tree Planting Plan is organized by district and includes recommended species by street, relative to the park-way width and other conditions- Rick Cross, Quality of Life Department, and a representative trom West Coat Arbonsts, answered Councilmernbers questions. Janet Ward, a member of the Street Tree Committee, urged approval of the Street Tree Planting Plan noting the fee paid to the West Coast Arborists, was fi-om private donations. Councilmembers thanked members of the Street Tree Committee and Quality of Life Department for their efforts and acknowledged with gratitude the planting of 250 trees by Mr. and Mrs. Ward, Councilmember Bean expressed concern that palm trees along the major streets should be preserved. Councilmember Harrison suggested a policy on, the urban forest be included as part of the General Plan, Councilmember Gallagher moved to adopt the Street Tree Planting Plan in order to provide a street tree palette of approved street tree species organized by the appropriateness of each tree species to planting space widths and specific conditions, Motion seconded by Councilinerriber Agullar and carried unanisous h., by roll call vote. Contract- Employee Dental Injurance - Human Resources Director Scott- Leistra reported the City received proposals from dental coverage carriers. Each proposal exhibited certain savings. In accordance with the Employee Memoranda of Understanding, the City met and conferred with all employee units and provided presentations for each plan. The employee units unanimously chose the Principal Financial Group plan which offered enhanced benefits to the employees as well as a savings of approximately $159,000.00 for a twelve month period on a contract of approximately $516,000.00. Coverage under this plan will be effective May 1, 2009. Councilmeniber Bean felt the staff report was not sufficient as it did not include information regarding the bidding process. Councilmember Gallagher moved to approve the contract with The. Principal Financial Group to Provide dental insurance for all City employees and authorized the Mayor to execute, and the City Clerk to attest to, the document on behalf of the City. Motion seconded by SCP ouncilmemleer Aguilar and carried unanimously by roll call note. April 21, 2009 Page 6