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245618 i 245 1� ORIGINAL TQ CITY CLERK "" , �" CITY OF ST. PAUL couNCi� ' ` OFFICE OF THE CITY CLERK �`E Nd. � COU E O UTIO� NERAL FORM PRESENTED BY (J COMMISSIONE �"�� DATF RESOLVED� upon the re eommendati on of the Health and Welfare Committee , that the Council of the �ity of Saint Paul hereby approves proposed drafts of documents to be transmitted by The Minnesota Mutual Life Insurance Company to each of the insured under the City� s group life insurance program, such documents including a form of notice regarding Beneficiary Designation, a copy of which proposed form has been marked "Exhibit A", attached hereto and incorpor ated herein by reference ; a proposed form of Beneficiary Change Card� copy of which has been marked "EXhibit B" , attached hereto and is incorporated herein by reference ; and a third document, being a proposed Certificate of Participation form, copy of which has been marked "Exhibit C" , attached hereto and is incorporated herein by reference. t`.?Rf�t � ,;i:V�D � ar oration Gc��y��,_l � � 0 �p 16 1969 COUNCILMEN Adopted by the Council 19— Yeas Nays �� 1 � �g�� Carlson Dalglish � pprovecL 19— Meredith Tn Favor Peterson ' Sprafkz d Mayor Tedesco A gainst Mr. President, Byrne 1�uetts�+E� SEP 2 0 1�6� 0 ' y �f�'' �� CITY OF ST. PAUL GROUP IvSURANCE PL�v I?iPORTA.vT ;IOTICE - BENEFICIARY DESIGNATION Everyone's faniily situation changes from time to time through marriage, death or birtli. For that reason a review of all beneficiary � designations should be made from time to time. At this time, a new certificate is being prepared to reflect your inerease in coverage throug:� the City of St. Paul Group Life Insurance Policy. All employees �aill receive one certificate which o�ill include all life insurance coverages available to an employee. We ask for confirmation of your beneficiary designation for the � prepar�tion of your certifi •ation. You need not specifically designate . a beneficiary because the new certificate contains an automatic provision for Che death benefit to be paid in the following order: 1. Your spouse, if living, otherwise to your living children. 2. Your parents or the survivor if one is deceased. 3. Your estate. � �Ct@: �i i.i18 e»j^.iC��E �S 3�^^�1°� . t�1° fl:5t tvnn �F �gcionotinn �Y.. .,� o......._....� of course, would not apply. The above represents the order of disposition most generally selected. You may make this selection or if you prefer any other beneficiary designation of your cnoice. In either case, you may also change the designation at a later date if you want to. Please complete and return the attached card in the envelope provided, so that your new certificate may be completed in accordance with your designated choice of beneficiary. EXHIBIT A • ___ � t_ , � -- . , � � I .. . , � ! CITY OF ST. PAUL GROUP HA;�� i INSURANCE PLAN DEPARTi1ENT BENEFICIARY CHANGE CARD :iarital Status � Single /% Married / / ' . � -- — . � Divorced / / Widowed / / � l. I elect to nave the proceeds payable in accordance with tae . � beneficiary listing in the policy. 2. I wish to specif ically designate (name and relationship) as the beneficiary of my insurance. � i Date ! Signature , i I i EXHIBIT B I i � � } . . , i i - ; GROUP LIFE POLICY 2u^81-G ' � , 'CERTI�ICAT� ; of ' GROUP LIFE POLICY 3S5s79-G i PAt'Z,- TICIPATION � GROUP LIFE POLICY 1520-G � � . � • i ' . � , Insurin; Employees oP � THE CITY OF ST. PAUL. MINNESOTA . � . � THE BOARD of EDUCATION, � - Independent School District 625, St. Paul� Minn. � � . . `- . _ . , i . ; . i . � . . ` .� , ... r. � , . � � ___.r � _,.' • . �ERTIFICATE IDENTIFICATION. CAR.D� '! , • '' _ I , -- � . � � _ . , f • . � • � . � CERT3FICATE You flre insured under one or more of the above numbered group lifo policies. The amount of your insurance undar Pach of tho policiey is shown on the Certificate Identification Card as of the certificate date. The ir.auranco is subject in every reapect to the tc�rms of the Group Polioy undor w2iich the coverage is pr�vided. Tlie Group Policy may be amnnded, cancelled, or discontinued by agrec�.ior.t batween xha Corn��:�ny 1nd the Policyholdcr. Ttiis Certiiic�te describes the most important provisions of the Group Policies as tlzcy affcet your insurance. Tho offective date of your insurance or inoroase in the amount of insurance is independeltyly determined for each policy and conditioned on your bein� aotively at worlc on the effective dato. If you aro not �etively at work on the soheduled effective date, any such insurance shall become efFectivo on the first day of your return to aotive work. This Certificate replaoes any and all C�:rtificatea of Covera�e issued to you under �he Above numbered Group Polioies. Read it oarefully. Keep it in a safe plaoe known to your fAmily. I ; LIr^E CC3Vr.1��iGE � PAYMEI�:T OF E3ENEP'ITS T2ie Conipany will pay the amount of your Basic Group Life Insurance and Option.�l Group Life Znsurance to youx beneficiary immadintely upon receipt of duo proof of death while insured under the Group Policy. You do not havo to na:ne a beno:iciarv. If you have previously desibnated a beneficiary, ' ��icli t:c�rieficiar s.iall revrzil until ou clian e it�T�you o not esignate � ene ►eiary, or i �iere is no` s+;ti�iie Leiieficiary surviv:ii� at t2io time of your daath, the amount of y�ur insuranoe will UQ paid ue- cording to t2ia following order of.priority: 1. Your surviving lawful wife or huaband; 2. Your surviving ehildren in equal ehares; 3. Your aurviving pa,renta in equal ahures; 4. The duly appointed legal repre-. sontative oP your estate. "Childron" nierane only first generation lowPul bodily issue and legally adopted persons. t , . I f,16452 e•e9 ' w i y EXHIB IT C ! - , . OR161NAL TO GITY CL[RK CITY OF ST. PAUL ��N�� . 245618 OFFICE OF THE CITY CLERK F��E NO. � • COUNCIL RESOLUTION-GENERAL FORM PRESENTED BY COMMISSIONER DATF RESOLVED, upon the re commendati on of the Health and Welfare Committee , that the Council of the �ity of Saint Paul hereby approves proposed drafts of documents to be transmitted by The Minnesota Mutual Life Insurance Company to each of the insured under the City� s group life insurance program, such documents including a form of notice regarding Beneficiary . Designation, a copy of which proposed form has been marked "E�ibit A" , attaehed hereto and incorporated herein by reference ; a proposed form of Beneficiary Change Card, copy of which has been marked "EXhibit B" , attached hereto and is incorporated herein by reference ; and a third document, being a proposed Certificate of Participation form, copy of which has been marked "Exhibit C", attached hereto and is incorporated herein by reference. �EP 16 1969 COUNCILMEN Adopted by the Cou ' 19— Yeas Nays � � � �� Carlson Dalglish Approved 19— Meredith _�n Favor Peterson Sprafka Mayor Tedesco ASainst Mr. President, Byrne �� . � - �456 �8 CITY OF ST. PAUL GROUP I;ISURA.'�CE PLt1�v IliPORTA.�T .IOTICE - BEVEFICIARY DESIGVATION Everyone's family situation changes from time to time through marriage, death or birtli. For that reason a review of all beneficiary � designations should be made from time to time. At this time, a new certificate is being prepared to reflect your inerease in coverage throug:� the City of St. Paul Group Life Insurance Policy. . All employees ��ill receive one certificate which will include all life insurance coverages available to an employee. We ask for confirmation of your beneficiary designation for the � preparation of your certificati�dii. You need not specific�ally designate . a beneficiary because the new certificate contains an automatic provision for the death benefit to be paid in the following order: 1. Your spouse, if living, otherwise to your living children. 2. Your parents or the survivor if one is deceased. 3. Your estate. 2: ti�nQ ^F '.��ang��;� ' ticte: ?f :.he e�Y�o�ee is s�r.gle, . th� f st -�r ... _o.. •, of course, would not apply. The above represents the order of disposition most generally selected. You may make this selection or if you prefer any other beneficiary designation of your choice. In either case, you may also change the designation at a later date if you want to. Please complete and return the attached card in the envelope provided, so that your new certificate may be completed in accordance with your designated choice of beneficiary. EXHIBIT A . � � __ -- - - . � J i n • � � 1 ; CITY OF ST. PAUL GROUP N�.� I INSURANCE PLAN DEPARTiIENT ! BENEFICIARY CHANGE CARD. :�arital Status � Single /% Married / / ' - . + Divorced / / Widowed / / � l. I elect to nave the proceeds payable in accordance with the . � beneficiary listing in the policy. 2. I wish to specifically designate (name and relationship) as the beneficiary of my insurance. � i Date ! Signature � � 4 . � � � EXHIBIT B 1 � ! I , + _..,: , � i . � ° ; GFOUP LIFE POLICY 2881-G � � CER,TI�ICATE � of � GROUP LIFE POLICY �f5^s79-G PARTICIPATION � GROUP LIFE POLICY 1520-G , . i � ! . Insurin; Employees oP � THE CITY OF ST. PAUL, MINNESOTA . ! . � THE BOARD of EDUCATION, � - Independent School District 625, St. Paul� Minn. i I . . - . ' i � i . ; j � , • � . ( , .._ i . � ' � � � � � i �� , __._ . . _____ I � , . _ • . CERTIFICATE IDENTIFICATION. CARD� •j � .. � _ _- --� - ` � � � ' ' I _ . � . i ' CERT��'IC�.2^E You Aro insured under one or more of the a�bove numbered group lifo policies. The amount of your insur�,nce undar Pach of tho policie� is shown on the Certificate Identification Card as of the certificate dato. The ir.suranco is subj�et iii every respect to the terms of the Group Polioy undor w2iich the cover:l�e is pmvided. The Group Policy may be flm�nded, ca:icelled, or discontinued by a,U-ee�.ie:t �atween :�hu Comp�,ny �nd the Policyholdcr. This Certificate desaribes the most important provisions of the Group Policies as tlzcy affcet your insuranco. Tho o:'fective date of your insurance or inoroase in tho amount of insurance is independeltyly dotermined for each policy and oonditioned on your beina aotively at work on the effective date. If you aro not actively at work on the soheduled effective date, any sueh insurance shall become effectivo on the first day of your return to aotive work. This Certificate replaces any and 111 Cartificatea of Covera�e issued to you under the obove numbered Group Policies. Read it oarefully. Keep it in a safe plaoe known to your family. � 1 ; LIr^E CGVE�.i,AGE ' • PAYMEI�T QF BENEZ'ITS Thc� Conipany will pay the amount oP your Basic Group Life Insuranee ssnd Optional Group Lif e Insurance to your beneficiary immediately upon receipt oP duo proof of death while insured under the Group Policy. You do not havo to name a beneficiarv. If you havo previously desionated a beneficiary, ' ��eli beneficiar �shall �rev�iil until ou clian e i"t�Tf you o not esignate n ene iciary, or i £'�Cieieis no ;,;�nie l�eiieficiary surviv:ii� at tYie tiine of your deat2i, the p.mount oP your insuranoe will bo paid ac- cording to tiio followin� order of.priority: 1. Your surviving lawful wife or husband; 2. Your surviving ahildren in equal ehares; 3. Your survivin� parente in equal aharea; 4. The duly appointed legal ropre-. sontative of your estate. "Childron" means only Pirst generation lawful bodily isaue and legally adopted persons. t , . { f;ieas2 e•69 ' w . i .. EXHIBIT C ! - , ♦ � / � . ` ,� � � ; GFtOUP LIFE POLICY 2a81-G ' ' - CEI-iTI�ICATL of GROUP LIFE POLICY �653'79-G PAr,,TICIPATION GROUP LIFE POLICY 1520-G . Insuring Employees of THE CITY OF ST. PAUL, MINNESOTA � THE BQARD of EDUCATION, � - ' Independent School District 625, St. Paul� Minn. s i ' ' � ; � . . � , . i . I . i � �.....� � ..�.�� I I f � - . CERTIFICATE ID�NTIFICATION, �ARII• .� - • � . , � _ _ . ` , N�`� I CITY OF ST. PAUL GROUP INSURANCE PLAN DEPART�SENT BENEFICIARY CHANGE CARD :farital Status Single /% D4arried /% • � Divorced /% Widowed / / • 1. I elect to nave the proceeds payable in accordance with the beneficiary listing in the policy. 2. I wish to specifically designate (name and relationship) as the beneficiary of my insurance. Date ' Signature i , , ; • . i EXHIBIT B ; , I � . � � .- i N, _ , .. , { . . . „� ,.. , __ ` �. ' .:�' , ,� . � i� i: � . . DUPLICATE'^O PRIh:£R � "�� 9 CITY OF ST. PAUL ��E NC�� NO. � � OFFICE OF THE CITY CLERK COUNCIL RESOLUTION-GENERAL FORM PRESEN7ED BY COMMISSIONER DATF RESOLVED, upon the re commendati on o� the I3ealth and Welfare Committee, that the Couneil of the �ity of Saint Paul hereby appro�es proposed drafts of documents to be transmitted by The Minnesota Mutual Life Insurance Company to eaeh of the insurecl under the City� s group life insuranee program, sueh documents �.noiva�.ng a form of notice regarding Benefieiary Designation, a copy of whieh proposed form has been marked "Exhibit li'�, attaehed hereto and incorporated herein by reference; a proposed form of Beneficiary Change Card, copy of whieh has �xeen marked r�E,�hibit B'�, attached hereto and is ineorporated herein by referenoe; and a third document, bein� a proposed Certificate o�' Participation form, eopy of whieh has been marked '�Exhibi.t C", attaohed hereto and is incorporated herein by reference. �� . �� COUNCILMEN Adopted by the Council 19_ Yeas Nays �,� ,�.. � , ._, Carlson i � �� v Dalglish Approved 19— Meredith _�n Favor Peterson J Mayor Sprafku A gainst Tedesco Mr. President, Byrne O " " - � , �� .. � . s�� . �::� CITY OF ST. PAUL GROUP I:ISURANCE PLAN I_�iPORTA.�T NOTICE - BENEFICIARY DESIG�IATION Everyone's fanuly situation changes from time to time through marriage, death or birth. For that reason a review of all beneficiary , designations should be made from time to time. At this time, a new certificate is being prepared to reflect your increase in coverage through the City of St. Paul Group Life Insurance Policy. � All employees �aill receive one certificate which will include all life insurance coverages available to an employee. We ask for confirmation of your beneficiary designation for the preparation of your certificati4oii. You need not specifically designate a beneficiary because the new certificate contains an automatic pravision for the death benefit to be paid in the following order: 1. Your spouse, if living, otherwise to your living children. 2. Your parents or the survivor if one is deceased. � 3. Your estate. I � I iivt@: Ti �1i2 �^^�^ L'E i� ��^n].c r1�nr, f?�gt t��nc �i 3ocint+orinn � Y �j "b a . _�N., ,o......�.,..� 1 of course, would not apply. i The above represents the order of disposition most generally selected. �, You may make this selection or if you prefer any other beneficiary designation of your cnoice. In either case, you may also change the designation at a later date if you want to. Please complete and return the attached card in the envelope provided, so that your new certificate may be completed in accordance with your designated choice of beneficiary. . EXHIBIT A ; . ,. � � � < <� > �� .��- � , �� - � �� , , � . �y .� � � .� �1. '- - , � i i . � � CITY OF ST. PAUL GROUP Np��1� INSURANCE PLAN DEPART�SENT BENEFICIARY CHANGE CARD :tarital Status !; Single / / Dlarried / / ' � Divorced / / Widowed / / � 1. I elect to nave the proceeds payable in accordance with the beneficiary listing in the policy. 2. I wish to specifically designate (name and relationship) as the beneficiary of my insurance. Date ' Signature i i i � i EXHIBIT B i i i ;