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246751 ORIGINAL TO CITY CLERK Z��t�� CITY OF ST. PAUL couNCi� � � .OFFICE OF THE CITY CLERK F��E NO. OUNCI ES UTION GENERAL FORM PRESENTED BY � ' COMMISSIONE �' �'� qTF RESOLVED, upon the recommendation of the Health and Welfare and Insurance Committee, that insurance contrac�s, as amended, for employees and dependents, retired employees age 65 and over, and early retirees, between the City of Saint Paul and the St. Pau1 Fire and Marine Tnsurance Company as exemplified by Policies CEO 920, CEO 921 and CEO 922, copies of which are attached hereto and made a part hereof by reference, and pro- viding for premiums as provided in Council File No. 246667, approved December 12, 1969, sha11 be continued in force trom month to month during 1970, subject to further action of the Council. FORf�I APPROV / Asst. Corporation Counsel �EG 19 1969 COUNCILMEN Adopted by the Council 19— Yeas Nays Carlson D�C 1 � ��s� Dalglish prover� 19_ Meredith � Tn Favor Peterson ' Sprafku Mayor �Against Tedesco Mr. President, Byrne PUQIISk#�� DEC 2'� 1�� i , � ..- . , . ., ....- e , ��"2�f� 1 COMPANIES, INC. � � SNriny you�round/M wor/d...�round fM e%ck ��s w��+cra+ sr., sr. r�u4 M�++. sswl ' December 9� 1969 Mr. John Devlin Personnel Assistant Civil Service Bureau , 265 City Hall � St. Paul� Minnesota 55101 , � � City of St. Paul Employees (Retirees) Policy No. CEO 920 ' Dear John: This letter serves to confirm our intent to provide coverage for eligible dependents under age 65 of insured retirees, under the active City Policy, _ CEO 920. This extension of coverage is provided without any additional � rate increase to the current retiree premium of $6.00. � I trust that the above information satisfactorily answers your questions, however, should you have any question, please don�t hesitate to let me hear � from 'you. � Cordially, , , . , �, ST. PAUL FIRE AND MARINE INSURANCE COMPANY � � � o � ,, , � / '� ; . ; Ralph A. Lionetti, Assfstant Secretary � , , • Health Underwriting Department , � ejd ' � , � � � � � � � r� , • - . ,, . , , _ � ._ � CEO 920 � NON—OCCUPATIONAL GROUP ACCIDENT AND SICKNESS POLICY A CAPITAL STOCK COMPANY THE ST. PAUL ST. PAUL FIRE AND MARINE �NSURANCE COMPANIES INSURANCE COMPANY "' �'�� . ��'�s�xy��,. ST. PAUI., MINNESOTA �� "�,_ �� (Herein called the Company) Serving you around the wor/d..,around lhe clock SCHEDULE Policyholder's Name and Address Cit of St. Paul St. Paul Minnesota 55101 Effective Date�� Term Januar 1 1970 12 Months * 12:01 A. M. , Standard Time, at the address of the Policyholder. The Company agrees with the Policyholder named in the Schedule to pay benefits to the extent provided as to each person insured (here.in called the Insured Person) for loss resulting from (1) accidental bodily injuries occurring to any Insi�red Person or covered Dependent which are the direct and independent cause of the loss (herein called such injuries), or (2) sickness or disease contracted by the Insured Person or covered Dependent (herein called such sickness) subject to the provisions, conditions and exclusions of this Policy. This Policy is issued in consideration of the application of the Policyholder, copy of which is attached to and forms part of this Policy, and of the payment by the Policyholder of the premium for each Insured Person in the manner and at the rates set forth in the attached Premium Schedule, to take effect on the date indicated in the Schedule, from which date all insurance years and months shall be calculated, and for the Term indicated in the Schedule. RENEWAL This Policy may be renewed for further consecutive terms by the Policyholder at the Company's premium rates in effect at the time of each such renewal. The Company reserves the right to establish on any anniversary date of this Policy new premium rates, provided the Company gives written notice to the Policyholder of such new premium rates at least 120 days prior to the anniversary d�te at which such new premium rates .will become effective. � PART I MONTHLY BENEFIT FOR TOTAL DISABILITY When such injuries or such sickness results in continuous total disability which totally and continuously disables the Insured Person and wholly prevents him from performing every duty pertaining to his occupation and requires him to be under the professional care and . attendance of a doctar, the Company will pay a benefit at the rate per month stated in the Schedule of Benefits contained in the Insured Person's Certificate of Insurance, commencing • immediately after the applicable Elimination Period s,tated in such Schedule of Benefits, but for not more than 6 consecutive months on account of any one accident or sickness, except that for total disability caused by any one period of pregnancy, Monthly Benefit shall.not be payable for more than 1-1/2 months. Form No. 12320 CSP Ed. 11-69 . . .. _ _ . .. .. �......,..�,,..r, Provided always that Monthly Benefit shall not be paid for more than 6 months� during any period of 12 months, for total disability caused by such sickness of the Insured Person after attaining age 60. PART II SURGICAL EXPENSE EXCEPT ON ACCOUNT OF PREGNANCY The Company will pay indemnity in the amount of the expenses incurred for a surgical pro- cedure per�£ormed by a Doctor upon the Insured Person, or covered Dependent, because of such injuries or such sickness, except pre�nancy, but not exceeding the Maximum Amount specified for the applicable surgical procedure in the Schedule of Surgical Procedures. For any surgical procedure not specified in the Schedule of Surgical Procedures the Company will determine the indemnity payable based on a surgical procedure of equivalent gravity and severity. The maximum indemnity payable for all such surgical procedures performed upon the Insured Person or covered Dependent because of any one accident or sickness is $200.00. When more than one surgical procedure is performed during the course of a single operation, indemnity in the amount of the expenses incurred for each such surgical procedure shall be payable, but the maximum aggregate indemnity payable for all such surgical procedures shall not exceed $200.00. Provided always that no indemnity shall be payable under this Part II when the amount payabl� under Part V of the Policy for visit(s) for treatment(s) by a Doctor made on and after the day surgical procedure(s) is performed would exceed the amount otherwise payable for the surgical procedure(s). PART III OBSTETRICAL EXPENSE The Company will pay indemnity in the amount of the expenses incurred for an obstetrical procedure named in the Schedule of Obstetrical Procedures performed by a Doctor upon the Insured Person, or dependent wife of the �nsured Person when covered hereunder, because of a Pregnancy but not exceeding the Maximum Amount specified in such schedule. Provfded always that no benefit shall be payable (a) for an obstetrical procedure performed upon the Insured Person unless the Insured Person was insured for Dependent coverage con- tinuously since the commencement of the Pregnancy, or (b) for an obstetrical procedure performed upon the dependent wife of the Insured Person unless the Pregnancy commenced while the insurance with respect to such dependent wife was in effect. SCHEDULE OF OBSTETRICAL PROCEDURES Maximum Description of Obstetrical Procedures Amount Caesarean Section, including delivery of child or children. . . . . . . . . . $100.00 Pregnancy, delivery of child or children (all types except Caesarean) . . . . 50.00 Pregnancy, ectopic (also ruptured). . . . . . � � � � � � � � , . � , � � , � 125.00 Pregnancy, before seven (7) months, including dilatation and currettage if necessary . . . 30.00 Only one payment, the larger applicable thereto, shall be made on account o£ any one PregnA.r.cv. _ 2 _ SCHEDULE OF SURGICAL PROCEDIIRES EXCEPT ON ACCOUNT OF PREGIVANCY The amounts stated in this Schedule do not or are not intended to fia or govern the fces charged for performing surgical procedures. Maxi- Maxi- Description m� Description ffi� of Surgical Procedure Amount of Surgical Procedure Amount ABDOMINAL SURGERY For compound fractures the maximum surgical pro- Abdomen, paracentesis.......... ...... ......... $ 13.35 cedure expense benefit will bc one and one-half Appendectomy. . .. .. . ..... .... ......... 133.35 times the amount shown above for the conespond- Appendiceal abscess.�drainage............ . ..... 100.00 ing simple fracture. For fractures requiring an Chalecysteatomy............. .... .. ... ...... . 180.00 open operation or skeletal traction�the maxirnum Cholecystotomy................ .... ...... .... 133.35 surgical procedure expense benefit will be twice Colostomy................. ...... ...... . . .. .. 133.35 the amount showa above for the conesponding Common duct� surgery... ... ... . . . . . .. . . . . .. .. 200.00 simple fracture, but not to exceed $200.00. Diverticulum, intestinal... . . . . . .. . . . . .. . . .. .. 133.35 prthopedic Gastrectomy� total or partial. . . .. .. . . . . . .. . . .. 200.00 Arthroplasty, any major joint.... .... .... .. .... 200.00 Gastro-eaterostomy...... ..... . .. . .. .. . . . . .. . . 180.00 Herniotomy� diaphragmatic..... .. . .. . . . .. . .. . . 133.35 Bone graft (long bone)... . ... . . . .. .. .. . . .. .... 200.00 Herniotomy, single. . .................. .. .... 100.00 Bunion operation.. . .. . . .. . . . . . .. .. .. ...... .. 46.65 Herniotomy� bilateral........... ...... ... . .. .. 166.65 Coccyx, excision of. . . .. .. . . .... .. . ... . .. 46.65 Intestines, anastomosis....... ... .. .. ...... . ... 133.35 �'Tanipulation of joint(s) for adhesions (regazdless Intestines, resection. . . . . . . . .... . ... .. .. .. .. .. 200.00 of number). . .... .. ...... ,. .. ...... ........ 33.35 Intussusception, operative reduction....... ..... Osteomyelitis, drilling bone cortex.. .. .......... 80.00 Laparotomy eaploratory.................. .... �166.65 Spi al fusion. . . . . ... .. ...... ..... .......... . 200.00 � 100.00 Tenonhaphy. . . . . . .. . 66.65 Pancreas� drainage. . . ................. ... 166.65 Tenotomy.. . .... .. ................ 33.35 Peptic ulcer, perforated� closure.......... .... .. 133.35 EAR, NOSE, AND THROAT•SURGERY • ••.. Splenectomy... . . .. .... .. . .............. . ... . Z00.00 Antrumpuncture..... ................. ...... 6.65 Antrum window..... . . . .... . ..... .... . 33.35 BONE, JOINT, AND TENDON SURGERY Laryngectomy. . . . .. .. .. ..... � �� 200•00 Amputations I��astoidectomy, simple..... . ...... ... . ........ 133.35 Arm... .. .. ......... ..... ............. .. .... 100.00 1�lastoidectomy, radical. . . .. . .. . ...... . ... 200.00 Finger or toe. . . . ... ....... .. .......... .. .. .. 20.00 Nasal polyps, removal, unilateral.... . . ... . ..... 20.00 Hand or foot. . . . . ..... .. .. . . .. ........ .. .. . . 66.65 Nasal polyps, removal, bilateral..... . . .... ..... 33.35 Hip. .. . ... .. . . . .... . ... ......... .. 200.00 Paracentesistympani.............. . .. .. .. .... 6.65 Leg, at or below knee...... ............. .... .. 113.35 Submucous resection... ..... ...... . . .... 66.65 Shoulder. .... .. . . .. ...... ... .. ..... ... .. .. . . ].66.65 Tonsillectomy or tonsillectomy and� Thigh.... . . . . . . . .. .. ... . . ... .. .. .. .. . . .... .. 133.35 adenoidectomy................... .... . ... .. 33.35 Dislocations-Uncomplicated Tracheotomy. . . . . .. . ............ .. .. .. .... .. 46.65 Elbow. . .... .... .. .... .. .. . . .. . . .. .. ..... . .. $ 33.35 Turbinectomy. . . .. .. .... .. . . .... . . .... ..... 13.35 Finger or toe. . . .... . .. . ... .. . . ........ .. .. .. 6.65 EYE SURGERY Hip........ . . . ... . ........ .. ...... .. .. .. .. . . 66.65 Cataract, needling... . . . . . .. . .. .. .. .. .. .... 33.35 Knee. . .... . ..... .. . ... ........ .. . . ...... 40.00 Cataract, removal.. 133.35 Knee, semi-huiar cartilage requiring Chalazion. . ... . �. � � � 6.65 open operation............. . . . .. . ...... .... 133.35 F.ntropion or ectropion� plastic operation. . .. . . . 80.00 Mandible. . . . ... ... ... .. .. .. .. ... . .. .. .. .. .. 6.65 Enucleation or evisceration. . $100.00 Shoulder. .. .. .. . . . . . .. .. ... .. . . . .... .. .. . ... 20.00 Forei body, rem val fr m ...... ... . . ... .. . . gn o o cornea or sclera.... . . 6.65 Spine... ... ... .. .. .. .. .. .. .. .. . .... . .. .. .... 133.35 Lachrymal sac, removal or dacrocystorhinostomy.. 66.65 Fractures-Simple Pterygium..... . .. . . . .... .... .. .. .. .... .... . . 40.(N) Carpal or tarsal bone, one (except os calcis or GYNECOLOGY astragalus). . .. . ... ..... ... ........ ...... 33.35 Baztholin's gland or labial cyst, eacision......... 40.00 Clavicle or scapula. . .... ................. .... 33.35 Carcinoma of the cervix-complete treatmeat.... 200.00 Femur or hip. . . .. ... ........ ............... 133.35 Cauterization of cervical canal with conization. .. 33.35 Finger or tce. . . .. ....... .................... 13.35 Cauterization of exo cervix. .... ..... .. ........ 6.65 Humerus.. .. .. . .. ... .. .... .............. .... 100.00 Colporrhaphy, anterior..... . .... . . . . . . ... .. 66.65 Mandible.. 66.65 Combined cervical and cystocele or Metatarsal or metacazpal bone, one. . . . ...... .. 20.00 perineal repair. ... . .. .. . . .. .. . . . . .. 100.00 Nose....... . ... . ...... ...................... 20.00 Dilatation and curettage, except as complication Olecranon. . . .... ...... ... .. ... .... .... ...... 46.65 of pregnancy.. .. . . .. .. . . . ...o.. . . 33.35 Patella.. ... . . .. .. .. .. .. . ....... 66.65 Fistula, vesicavaginal or rectavaginal...... .. .. 133.35 Pelvis (coccyz excepted).. .. . .... ... ...... .. 133.35 Hysterectomy, subtotal. . ... . . .. .. .... .. . ... .. 166.65 Radius and ulna involving shaft................ 66.65 Hysterectomy� total. .. .. .... ....... .... .. 200.00 Radius or ulna or Colles' fracture... . .. ........ 46.65 Oophorectomy and/or salpingectomy. . ....... .. 133.35 Rib, one or more. . 13.35 Perineorrhaphy, including rectocele........... .. 66.65 Spine, compression fracture... . . ... ...o....... . 133.35 Trachelorrhaphy. . ....... ... ... 33.35 Tibia and fibula except Pott's fracture........ .. 100.00 Uterine polypi� removal. .... . ... .. .... .... .. .. 33.35 Tibia or fibula including Pott's fracture......... 66.65 Uterine suspension. . . . . ..... ... .. ........ .... 133.35 19223 RHS Ed. 8-69 00'� ''' '' '''IIot�oa[ut uoBa ';o uoi��a[ui 'sutan aso�u�A 00'OOT ............:.Ig=a��q 'uian snouaqd�s 'uoi��iZ S9"99 ..............apts auo 'utan snouaqd�s `uoi��e�tZ S9'99 ....... . . . . . . . . . .. . .. ... . . . . .�uzoa�aia�o�r�A utaA aso�usA S9'99I .. .... .. ........ .. .. . ...... .�cuo�oq�ti-oia�asn �o� '�ftuo��a to.uC S9'99I .. ... . ....... .. . . .j�sq�amsu�s� '�ti.uo3�a�s�sosd 00'OOZ .. .. .. .. . ... .. .... .. .....TE P. us 00'OOZ .... .. ...... .. .. . . .. . . . . . . .. .....�auuad ao S£'££T � � �� '� '�'�'''l�o�-qns '�uxo3�apioidu,L �sa�s3s om� io auo '�Tqnd�idns '.Suio��a�E�sold 00'OOZ ................... . .�a�ajdcuo�) �C�sejdo�v�Uqs S9'99 ...... .... . . .... .. .. . : . . .. .. .....�cuo��a i �i S9'9 .............. .... . .��ea `sii�s 'x�eioq;oiunaud .......... ... .. .. . . . .. .... .. .. .. 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P�T I� ANESTHETIST EXPENSE The Company will pay indemnity in the amount of the expenses incurred for administering of " anesthetic by an anesthetist (not a salaried employee of a hospital) to the Insured Person� or covered Dependent, when required in connection with a surgical or obstetrical procedure for which indemnity is payable under this Policy, not exceeding 20% of the Maximum Amount specified for the applicable surgical or obstetrical procedure performed as shown in the Schedule of Surgical or Obstetrical Procedures. . - ' PART V IN-HOSPITAL MEDICAL EXPENSE BENEFIT The Company will pay indemnity in the amount of the expenses incurred for visit(s) for treatment(s) made by a Doctor while the Insured Person or covered Dependent is confined as a registered bed patient in a Hospital because of such injuries or such sickness, except Pregnancy, not exceeding $4.00 for each day such visit(s) for treatment(s) are made during such confinement, but not more than 120 days on account of any one accident or sickness. ° Provided always that no indemnity shall be payable under this Part V for expenses incurred ; on and after the day a surgical procedure is performed unless the amount payable for such � visit(s) for treatment(s) by Doctor mede on and after the day surgical procedure(s) is performed would exceed the amount payable for surgical procedure(s). PART VI ACCIDENT FIRST AID TREATMENT AT CLINIC OR DOCTOR�S OFFICE OR AT HOSPITAL AS AN OUT-PATIENT The Company will pay indemnity in the amount of the expenses incurred except such expenses ; for which indemnity is otherwise payable under this Policy, for emergency first sid treat- � ment received by the Insured Person, or covered Dependent, at a clinic, Doctor's office or i at a Hospital as an out-patient, because of such injuries, within 72 hours immediately following the occurrence af the accident, or at a clinic or poctor's office beginning within 10 days after receiving emergency first aid treatment at a Hospital as an out-patient, not exceeding in the aggregate $25.00 on account of any one accident. PART VII DIAGNOSTIC PROCEDURE EXPENSE The Company will pay a benefit in the amount of the expenses incurred by the Insured Persoa for an X-ray or laboratory examination which is made for diagnostic purposes upon the recom- mendation of a Doctor for the Insured Person, or covered Dependent, while not confined as a registered bed patient in a Hospital because of such injuries or such sickness, except Pregnancy, but not exceeding in the aggregate $100, for each Insured Person or each covered Dependent because of all accidents and sicknesses occurring within any period of 12 con- secutive months, provided that no payment shall be made hereunder for any expenses for which benefits are actually paid under Part VI. PART VIII MAJOR MEDICAL EXPENSE When on account of such injuries or such sickness occurring to the Insured Person or covered Dependent, Covered Medical Expenses are incurred in excess of the Deductible, the Company will pay 80% of the amount by which the Covered Medical Expenses exceed the Deductible� but not to exceed the Maximum Aggregate Benefit. The Deductible shall be equal to the sum of: . (1) the amount payable for Covered Medical Expenses under any other benefits provided under this Policy; and - 3 - �.-�.t,�. .. _.._. _..�_. _�.___ n _ .. . . .. � � . � . .. „ . � . . . � � . ._ � . .. .. ..._�.-..�.�,�r+ ' (2) a cash deductible of $50.00 applicable to each person insured, except (a) if, during the same calendar year the Tnsured Person and his covered Dependents incur a total of $50.00 of Covered Medical Expenses, no further cash deductible will then be required in the remainder of that calendar year for the Insured Person or any covered Dependents, and (b) the cash deductible will not apply to expenses incurred for which benefits are payable under Part II or Part VI. The Deductible will apply each calendar year, provided that any Covered Medical Expenses incurred �nd applied to the Deductible in whole or part during the last 3 months of any calendar year may be applied toward the cash Deductible for the next calendar year. The Maximum Aggregate Benefit under this Part with respect to each person covered hereunder during such person's lifetime shall be $10,000.00, provided, however, when such person has received payments under this Part amounting to $I,000.00 or more, he may have his Maximum Aggregate Benefit restored by (1) furnishing at no expense to the Company, satisfactory evidence of insurability, or (2) if an Insured Person, completing a continuous 6 month period of full-time active work for the Policyholder, and (3) if a Dependent, completing a period of 6 consecutive months without medical care or treatment and fully engaging in the regular and customary activities of a person of good health and of the same age and sex. . Hospital charges or charges normally made by a Hospital for care and treatment while con- fined as a registered bed patient are not considered Covered Medical Expenses. Covered Medical Expenses shall include the customary charges for the following necessary medical treatment, surgery, and services and supplies which are recommended or prescribed by a Doctor: (1) the services of legally qualified Doctors and physiotherapists (including Kenny treatments); (2) the services of registered graduate nurse(s) other than a nurse who ordinarily resides in the Insured Person's home or is a member of his immediate family; (3) drugs and medicines requiring a Doctor's prescription; (4) laboratory services, blood transfusions, X-ray examinations (except X-rays of teeth) and X-ray treatments, including radium and radioactive isotope therapy; (5) rental of an iron lung and other mechanical equipment; (6) oxygen and rental of equipment for the administration of oxygen; (7) rental of a wheel chair and hospital-type bed; (8) anesthetics and the administration thereof; (9) artificial limbs and eyes; (10) cast, splints, trusses, braces and crutches; (11) transportation by a professional ambulance to or from a Hospital; and (12) treatment of injuries to natural teeth, including initial replacement of natural teeth or setting of a fractured jaw, resulting from an accident occurring while the insurance with respect to the person is in force. - 4 - _.. _ , , . . , . . .. _ ..._,,�;,.�.., 3 DEFINITIONS A. "Dependent" means only the Insured Person's spouse and unmarrfed children (including step-children, legally adopted children and foster children) under 19 years of age if not a student, or to age 23 if a student or to the date of marriage, whichever is earliest. The dependent child age limits shall not apply to a dependent child who is incapable of self-sustaining employment by reason of inental retardation or physical handicap and is chiefly dependent upon the Insured Person for support and maintenance and who becomes so incapable or dependent prior to attainment of the age limits stated herein, if the Company has received satisfactory proof of such conditions within 31 days of such dependents attaining said age limit. B. "Total Disability" with respect to an Insured Person means the inability to perform every duty pertaining to his occupation while under the care of a Doctor. . . C. "Total Disability" with respect to a covered Dependent means complete incapacity, while under the care of a Doctor, resulting from accidental bodily injury or sicicness which • (1) whally prevents the Dependent from carrying on the regular and customary activities of a person in good health and of the same age and sex, or (2) requires hospital confine- ment. D. "Pregnancy" shall include resulting childbirth or miscarriage or complications therefrom. E. "Doctor" means any person, other than the Insured Person or a member of his family, who is recognized by the law of the state in which treatment is received as qualified to treat the type of injuries or sickness for which claim is made. F. "Hospital" means only an institution operated pursuant to law for the care and treat- ment of injured or sick persons, which has organized facilities for diagnosis and surgery and 24-hour nursing service. In no event, however, shall such term include an institution which is principally a rest home, nursing home, convalescent home or home for the aged. EXTENDED COVERAGE A. Applicable to Parts II, IV, V, VI and VII - When the Insured Person within 90 days immediately following termination of his insurance under this Policy, is confined in a Hospital or undergaes a surgical procedure, upon the recommendation of a Doctor, because of the same such injuries or same such sickness, except Pregnancy, which caused Total Disability beginning while such person's insurance was in effect and continuing until the date such confinement commences or surgical procedures is per- formed, the Company will recognize claim therefor in accordance with this Policy, provided it would have been a valid claim had the insurance not terminated. B. Applicable to Part III Only - When the Insured Person or dependent wife of the Insured Person when covered hereunder, within 9 months immediately following termination of insurance under this Policy with respect to such person, undergoes an Obstetrical Procedure on account of a Pregnancy which commenced while such insurance was in effect, the Company will recognize claim therefor in accordance with Part III, provided (a) it would have been a valid claim had the insurance not terminated, and (b) the termination was not due to failure of the Insured Person to make a required premium contribution while remaining eligible. - 5 - C. Applicable to Part VIII Only - Should the insurance of the Insured Person or covered Dependent terminate for any reason except payment of the Maximum Aggregate Benefit or because the Insured Person failed to make the required premium contribution when due� coverage for such person will be extended in the event of such person's Tota1 Disability at the time of termination, but the extension will apply solely to such injuries or such sickness which caused the Total Disability and then only during a continuous period of Total Disability and not beyond 18 months from the date termination occurs. SUCCESSIVE BENEFIT PERIODS A. Benefits as provided in this Policy are payable for such injuries or such sickness or Pregnancy, but for not more than one during any one period of time. B. With respect to the Insured Person, successive procedures, services and treatment for which benefits are payable under Parts I, II, IV, V and VII shall be considered as having occurred or having been performed on account of one accident or one sickness unless they are the result of entirely unrelated causes or are separated by the Insured Person's return to active work on full�time for at least 2 weeks. C. With respect to a covered Dependent, successive procedures, services and treatment for which benefits are payable under Parts II, T.V, V and VII shall be considered as having occurred or having been performed on account of one accident or one sickness unless they are the result of entirely unrelated causes or are separated by an interval of 3 months or more. EXCLUSIONS Anything in this Policy to the contrary notwithstanding, the insurance hereunder shall not cover: A. Under Parts I, II, III, IV, V, VI, VII and VIII: (1) accidental bodi2y injuries arising out of or in the course of e.mployment or sickness for which the Insured Person or covered ' Dependent is entitled to benefit under any Workmen' s Compensation, Employers' Liability, Occupational Disease or similar law or act; nor (2) accidental bodily injuries sustained or sickness contracted by the Insured Person or covered Dependent while on active military or naval duty or which result from an act of war (declared or undeclared); nor (3) suici�� or any attempt thereat while sane or insane; nor (4) intentional.ly self-inflicted injuries nor (5) no benefits will be paid to the extent such benefit payment duplicates any bene- fits payable under Group �ccident and Sickness Policies CEO 921 and 922. B. Under Parts II, III, IV, V, VI and VII: (1) expenses incurred for treatment or while confined in a state hospital as a non-paying patient or in a Federal or Veterans Administration hospital or at the direction of the Veterans Administration as a non- paying patient; nor (2) Pregnancy of any dependent child. C. Under Parts II, IV, V, VI and VII, dental surgery or dental work or dental treatment of any nature or eye examination or the fitting of glasses. D. Under Part VIII: (1) Pregnancy, except expenses incvrred for (a) an operation for extrauterine Pregnancy, (b) intra-abdominal surgery, (c) pernicious vomiting of Pregnancy (hyperemesis gravidarum), (d) toxemia with convulsions (eclampsia of Pregnancy), or (e) complications arising after 90 days from the date a covered Pregnancy terminates; (2) routine physical examinations, hearing aids, eye refractions or examinations, or the fitting of eye glasses or hearing sids; nor (3) expenses incurred for cosmetic surgery except to the extent necessary to repair disfigurement due to an accident occurring while insured hereunder; nor (4) expenses incurred for treatment of alcoholism or narcotic habits; nor (5) expense incurred for services and supplir� ��L which the Insured Person or covered Dependent shall not be required to make payment. - 6 - �'[tAO:!�W�� ?;n '�� ?�s�� 'F;�r.� : ,'�:�� ,._. :rr.. r: , . 1:�_ ��.,c. a . ,�i..'v!�i� z�n�� 3t_�� ro .. _ _..-. rT � . .7�1;.,_ �� _ .,�=3i}, ,'_? 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[ ` ,. „ ,'�_( ...-. ,� -; �..� , . , . S b . � �� " ' . � � t . . �'i�l6l3f:`9'.,!.x'!,�„�k?"i`��,».r�ta.,�..;�".; , t�;•. .�x„ `i�w i." . :u,:� .... � .,;t..'1:.�:i • � . . C c Vt ` ' .,t ' . Vlt".? 1t7 "D1�1 : !l: d0 ��7;1t<' 1(Uil�ryc�t �:l � t'' � I �,i,. i " _ �y ,.,a, �,.' -:.r i '.�.: t ',7 �:. 2 � �.� .' o '��2�'�9��1 ;PO"9� Yi.CSA,'!'1� V.}i.t.j�:�:.."�1�5�.��^'�� . , _�_� . .�(i'� �'� , - . . .. , ',� . > _, s�. 9tc74 '� {;;'h1 f . l�. � t . "i � �.i.. q�flCl � �7..3C��"94 l'� jh T�tvJ .�, ':�. � y�3 � A y�' _' ' .., � "r� ..�_ � Y � 1� r:S1�C :� . . . � 1'ipliS <Af;i :9Jt+�1 .,}^ �,�C y �� 0�� C,.1�'. �� - - {_i'�.1 . � .�_ 3 . :k 4 �, 'lt { .A� i6�'��t�i. .,�Yi lr Li`i.l . �i r. �.r� } � r� , � . � si't f 1-.. .1 . � � ,n1�'�T l � 4i.�a;��l�7�t5��fi�C.ty}`�.�'f�5 U��1�2ff4YJi !�[il'. _�'.. .r� U'�.t.. . . . . . . �''{_ . . �� !. - - .. ' . . ,-�� . ' r . . ;.= ,. .,. ,. .. , tt ,. : .1 - ,.. .. ; ', ,�,:.. n� J: ¢s j � , . .__.u.u.:�. .._._ .. -_.,_:�dr��,_.�, . �.--��,F-...�._...- =' �� . � . .. . ...___y.a. . _>a..'v1.,.csr.. ....�[:�i . . c:..�a.�..0 � .. . • - . , . �- Non-Duplication af Bene#its Prov!:is�on � � . This provision shall apply only to the benefits of this policy (or�ertifiECte to which this proxision is attached� shown under "This Plan" below and sholl supersede any other provision of the policy which is designed to prevent the duplication of benefits. ' Section A. Definitions (1) "Plan" means any plan provicfing benefits or services for qr by reason, of rriedica( or dental car� ac�r.r�fireatment, which benefits or services cre provided by (a) group, bldn�tet or fcartichise insurance coverage; (ki)'any group hospital service prepayment plan, group medico�l>service prgpCqrrrent plan, group practi�e ar�sther group prepayme{�t cover- age, (c1�any coveragr under.labor-inbnagem�enf trusteed plans, uniQn weFfare plans, employer orgaaiYalion plans, ' or employee benefit organiiqfion� plan's, and (d) any coveF.�g�'li`nder governmental f,pcograrHs; �and any coverage ,required.�or>provided�rby any statute. • �< �'` - The tefRn'"Plan'' shall be construed,x+epatately with respect tp each�policy, c<sntract, or,ottrer a�rcngement for bene- ' 'A .. ...�....� ,: fi,s.or s�tvices and separafefy with respect to that,partiqn'of,pnq iuth poiicy, carltract, or other arrangeme,ht�vh?ch ^ `reserves the Eight#o,tQke the benefits or.se�vice's Qf�.ofher Plans in�a,co�sideraFioo�in determining its benefits and that ? �ortion whi4b.<doe's'i�ot. ' .. , _ ,� f . .� ' .. ` . � . .: r. � , � .,.' ,_.� � �-� . °......,.. ,. '; . . -' � . - � , , ; �.,. •" .,,(2) �''Thii Ptan"��pearns all ben'efit"s of the polic�otfier than Accidentaf De,ath.nnd Dismemberment and Accident and 5ick- ness insurance, if provided thet�in. „ � ' (3):"Alfowcble 6x�s�*nse" means cny nec��sary,'•reasonable and customary item of expense at.least a pQ�tion of which is.covered underat least one.of tKe Plans covering the person foc,wtibm claim is made ��'�� ='' • When o�Plan provid'es.be�ef,ts in the form of services°,r�ther than cQsh�prrymenis,'the reasonable cash value,of;ea�A s.ervice rendered shcff be deemed to be,botFr an Allowp�le�Expense.,arsd-'a'benef►t.ppKd: ' ` (4�;"Claim Determination Period" means a calendar yecrr ov,'if s'horter, that portion of a ccl•endar year during which a covered ° '"- person is insured under this Plan.=,. - � ; ,, -. - �.. . � � .. . i � . . .. _5�- � .. .� i. , �� .t '• . .. .. . -.. _ `Section 6. Effect on Benefits (1) This`provision shall apply in de#era�ining the benefits as to a person covered under this Plan for qny Claim 'betecFni- nation Period if, for the Allowable Expenses incurred as to,such person during such period, the'sum,of" � ` (a) the benefits that'would be payable under this Plan in the absence of this provision, and' (b1 the benefits that would be payable under al.l other Pfans in fihe absence th�rein of provisions of similar purpose to this provision ' would exceed such Allowa6le Expenses. s (2) As to any Claim Determination Period with respect to which this provision is applicable, the benefits that would be payable under this Plan in the absence of this provision for the AllowaFile`Expens�s incurred as to such person during such Claim Determination Period shall be reduced to the extent"necessary so that the sum of such reduced benefits and all the benefits payable for such Allowable Expenses under all other Plans, except as provided in item (31 of this Section B, shall not exceed the total of such Allowable Expenses. Benefit� payable under another Plan include the benefits that would have been payable had claim been duly,.made therefor. (3) If _ (a) another Plan which is involied in item (2) of this Section B and which contains a provision co-ordinating its benefits with those of this Plan would, according to its rules, determine its benefits affer the benefits of this Plan have been determined, a�d (b) the rules set forth in item (4) of this Section B would require this Plan to determine its benefits before such other Plan then the benefits of such other Plan will be ignored for the purposes of determining the benefits under this Plon. (4} For the purposes of item (3I of th+s Section B, the rules establishing the arder of benefit determination are: (a) The benefits of a Plan which covers the person on whose expenses claim is based'other than as a dependent shall be determined before the benefits of a Plan which covers such person as a dependent; (b) The benefits of a Plan which covers the person on whose expenses claim is based as a dependenY of .a mctle person shall be determined before the benefits of a Plan which covers such person as a dependent of a female person; . - (c) When rules (a) and (b) do not establish an order of benefit determination, the benefits of a Plan which has cov- ered the person on whose expenses claim is based for the longer period o# time shall be determined before the benefits of a Plan which has covered such person the shorter period of time. Section C. Right to Receive and Release Necessary Information For the purposes of determining the applicabiliry of and implementing the terms of this provision of this Plan or any provision of similar purpose of any other Plan, the Compa.ny moy, without the consent of or notice to any person, release to or obtain from any other insurance company or other organization or person any information, with respect to any person, which the Company deems to be necessary for such purposes. Any person claiming benefits under this Plan shall furnish to the Company such informotion as may be necessary to implement this provision. 16094 NBP Rev. 11-69 Printed in U.S.A. � (over) v � l�,�i�'�dRf�� 3��'�?��.a��N 3N12i1�IFw �'��" ��f� °�f'��'�'� `�.� � _ . � •sus�i�a�a±��k��a ��y�o �uo °sa�F�s��ua�:� ��u�ansui �ay�� av�s :ar�;cr��a�aP Iloy:��tucdwo� ay� so '6u�iwA� �. � , �•lo} �u;, �c� ��s¢ew a� auo 6ss�+�ui u�,=3z� '�€aa�s�a a��E,�s �� ,�a��a at�� `s;uawkcd �psns aanaaa��o��y6i� �yg anc4 li�ys �(u�d �-ua�� t�� '�e�«;exrs��i 3�y;��u��F�y ,��,�b d'y<<<.�s �� r;�?;��{�4r� ��r ,gu��d.�� pr�r��a4 v�nuiAx�� yd }o ssa�xa ui 'auai� �,uA �� '{u�ow� r--;�; !� �+a sasua.r? ��•�r�w�o��;�+ �,,, :s,:��dg�r� �;o� �u�ad��Q�� fa� 3�ou� v;,�a� �nn� s�uausHnd �anaua4M e�a,�o�a� �o �y�i�g °3 uoi�9�� •�ua�6d 8ta�� ap�u� l(�i�iqua� wo�� paf:��ay�siP �Il�"� aq Ilo�� (�r�daaoa ��•�� 's�uaw a�(nd �;�ns ;d �ua�r�a ay; o; °¢au� aAe�� s�y� �apun �r�cd s�ya��q aq o; ��,-o aq Ilqys psAd o€ ��unowo puo '�oisines,�r! s�y1 ¢��a�ui ay�kss�ae�s �„ .�ap�o u� �a�^:�_a�nn��g o� auiw��saP �9AV;; �f SFUfl�P�41"A r�ffq S{UdUl�.t)CI .l�l�{O t�a115 EUi�DIU SUOI�DYIU�6J9 �Su� �� anu �(r�u c?.ti ��AF�;gaa�si� a�os s�K �i p�� u�En a�qnsas�� '�{:�� r-�r-i��r ��y, Aucdauc�� y� 'suA�� ayyo bas� �apurt � apnw uaaq aRUy �ao�seno�� seyi yii�n a��p�o��o us r�pf� sAy� �a�� F�� r��+ac� ano4 P,no�� y�iy� s�ua��u�(od �anaua4M ,,,��,�, �� .�.�6� : °;;:� ��o, :f; „_�. , . . .. . , �,r...:..,. ' � ELIGIBILITY The Policyholder through its Council shall have the sole responsibility initially to determine the eligibility of all employees for insurance hereunder and the Company agrees to be bound by such determi.nation of eligibility. On and after the effective date of this Policy, change or modification of the categories of employees eligible for coverage shall be determined by resolution of the Counci.l, subject to rejection by the Company by written notice to"the City Clerk within 10 days after transmittal of the resolution by the Policy- holder to the Company. EFFECTIVE DATE OF INDIVIDUAL INSURANCE The normal e£fective date of the insurance of an employee who is required to make contri- bution toward the cost thereof, shall be the date the employee becomes eligible for such insurance or the date the employee makes written application and authorizes payroll de- duction of the required premium, whichever date is later. The normal effective date of the insurance of an employee who is not required to make con- tribution toward the cost thereof, shall be the date the employee becomes eligible for such insurance. When an employee is absent from work on the normal effective date because of temporary lay-off or leave of absence, not i.ncluding sabbatical leave, sick leave or compensatory disability leave, the insurance shall not take effect until the employee returns to active work on full-time. EFFECTIVE DATE OF INSURANCE WITH RESPECT TO DEPENDENTS The normal effective date of an employee's insurance with respect to his Dependent(s) shall be the date of the employee's eligibility for insurance or the date the employee applies for such insurance and agrees to make the required contribution toward the cost thereof, whichever date is later. An employee's insurance with respect to a Dependent who is totally disabled on the date suc,h insurance otherwise would become effective shall not become effective until the date the total disability of such Dependent has terminated. Tn no .event shall an employee's insurance with respect to his Dependent(s) become effective before the insurance with respect to the employee becomes effective. E��IDENCE (1F T'vS!��?;ABIL7TY Each employee required to make a contribution toward the cost of his insurance hereunder who does not apply for such insurance within 30 days from the clate of becoming eligible therefor or whose inS.urance tprmin�tes whi_1� c.�mair�iaig elig-i�l�, �l�a?ll` be required to furnish .eviden�e of insurabil,ity with• �es.pect.;,ro hiT�self; <s�ti-sfac•tiar3u=a�d�`�t;��}xa�i�`•��pense , _ . . , . , to the Company. , , . _ , ,-. . � ,�. .�;; :,.` ��,� � .. ,�; �� , _ . � -� �.�r k��, � � � :,� �_� , . �t,G �r . _ Each employee who applies for insurance hereunder with respect to his Dependent(s) (1) more than 30 days after he fir'st becor��"�elig5'�le'-`for such insurance, or (2) more than 30 days after the date he becomes eligible for insurance with respect to himself without cont.ribut.i.on on �,is R.art towar�d th�re:ost thEreof, shall be eligible for such insurance upon furnishing evi.�ier�c,�.,�f: i�surahility wi��E�resp�ct' 'tts?,''such� De�en�eri`t(`s�`-"'`° satisfactory and wit.hout expense r_o ;the ;Com�any. y, c�, �: „ � 4 `� '.' -` ;<::� �.-u”: c:� . . ,i _ .. . . _. _. _._. . . . .;'s�. „ ��f- . , . � :.A _ ....,. .. . . ,. . ,... , . . ,, . . The effectiv� �date Qf thQ emplovPe' G� ir.suran�e,�;�.r„clucl?ng ��asurance'��with�' respe�C`t;'tct`��is Dependent(s), who is required �to furn.ish evidence of insurability shalt be the date of the Company's apprqual of such F�<��fl�rice c•i I�sura�il�ity. - 7 - � ' ..d w_...:w.a.ai�Yi(� TERMINATION OF INDIVIDUAL INSURANCE The Insured Person's insurance shall terminate automatically at the end of the insurance month for which his premium was last paid and accepted by the Company in the event: (a) this Policy is lapsed or discontinued; or (b) the required premium payments cease to be made on the account of the Insured Person or the Insured Person cancels or withdraws his payroll deduction authorization; or (c) the Insured Person terminates his employment with the Policyholder; or (d) the Insured Person is pensioned or retired; or (e) the Insured Person enters active duty in military or naval service; or (f) the Insured Person is temporarily' laid off, granted sick lesve without pay or granted a written leave of absence, provided, however, that insurance not terminated for other cause stated in (a) through (e) above� may be continued for not exceeding 6 months by payment of the required premiums for such insurance directly to the Minnesota Mutual Life Insurance Company, St. Paul, Minnesota, acting as collecting agency for the Company on or before their respective due dates. TERMINATION OF INSURt1NCE WITH RESPECT TO DEPENDENTS The insurance of the Insured Person with respect to a covered I)ependent shall terminate automatically at the end of the insurance month for whi.ch his premium was last paid and accepted by the Compan.y; (1) in the event of the discontinuance of this Policy or failure to make any � required premium payment or contribution; or (2) in the event of the_ termination of the Insured Person's insurance under this Policy; or (3) in the event a Dependent becomes eligible for insurance under this Policy as an Insured Person; or (4) in the event the Dependent no longer qualifies under the Dependent definition; or (5) in the event the Insured Person receives compensation from the Policyholder for injuries arising out of employment; provided, however, that insurance not terminated for other cause may be continued for the period he receives compensation payments from the Policyholder for temporary total or temporary partial disability by payment of the required premiums for such insurance directly to the Minnesota Mukual Life Insurance Company, St. Pau1, Minnesota, acting as collecting agency for the Company on or before their respective due dates. - 8 - � . .; :.. : .�,«.:�,�:: REINSTATEMENT OF INDIVIDUAL INSURANCE An Insured Person whose insurance hereunder ceases for any reason shall be eligible again to insure hereunder upon being reinstated to active employment by the Policyholder, pro- vided the employee meets all other eligibility requirements herein stated, but an employee who applies (1) more than 30 days after the date he becomes eligible, or (2) after the insurance ceases because of failure to pay the required premium while remaining eligible, shall be "required to furnish evidence of insurability satisfactory and without expense, to the Company. MONTNLY PREMIUM STATEMENT The Company will send to the Policyholder through its collecting agency, the Minnesota Mutual Life Insurance Company, a monthly premium statement. The Policyholder will furnish on the Company's forms such information relative to new Insured Persons and termination of insurance as is necessary to enable the Company to prepare such premium statements. If any such information is received too late for the changes to be included in the current premium statement, proper charge or credit therefor shall be given in a succeeding premium statement. ' PREMIUM PAYMENTS Al1 premiums for insuranc.e, except as otherwise specifically provided, are payable solely by the Policyholder to the Minnesota Mutual Life Insurance Company, St. Paul, Minnesota, acting as collecting agency for the Company on or before the dates upon which they fall due. TERMINATION OF POLICY All insuranc.e under this Policy shall terminate at the end of the Grace Period when the required premium is not paid. The insurance of every Insured Person, i.ncluding insurance with respect to his covered Dependent(s), shall immediately cease upon discontinuance or termination of this Policy but without prejudice to a_ny claim arising prior thereto. NEW EMPLOYEES All new employees of the Policyholder who become eligible for insurance under this Policy, in accordance with the provisions hereof entitled "Eligibility" and "Effective Date of Individual Insurance", shall be added to the class or classes of employees originally insured. EXPERIENCE RATING This Policy is subject to the Company's experience rating plan under which the Company may adjust the premium rates on any Policy anniversary date (subject to the required notice hereinbefore provided) and, in addition thereto or in lieu thereof, the Company, at its option, may make a re.troactive rate reduction for the previous policy year with a consequent refund of premium for that policy year payable in cash to the Policyholder. If, at any time, the aggregate amaunt of such refund exceeds the Policyholder's share of the aggregate amount of premium paid hereunder, such excess shall be applied by the Policyholder for the sole benefit of the insured employees. Payment of any refund to the Policyholder shall completely discharge the liability of the Company with respect to the refund so paid. No increase in premium rate shall be retroactive. - 9 - CONVERSION PRIVILEGE When an insured employee retires, terminates his employment with the Policyholder, or is on temporary lay-off or written leave of absence for more th�n 12 months from employment with the Policyholder, other than si.ck leave with pay, the Company, upon receipt of fully completed and si.gned application from such person, within 31 days from such retirement, � termination of employment or in the case o£ temporary lay-off or written leave of absence within 31 �days from the end of the month the premium was last paid and accepted by the Company, will issue an individual policy which shall provide substantially the same bene- � fits for which he is insured hereunder at the Company's regular premium rates for such benefits at the time of conversion; provided always that this conversion privilege shall not apply to any person to whom such an individual policy has been previously issued and is in force. Such individual policy shall be issued on quarterly, semi-annual or annual premium basis and shall be renewed from term to term by payment of the premium in effect at the time of renewal. Provided always that this provision shall not appl.y to the coverage under (a) Part I, Monthly Benefit For Total Disability, or (b) Part VIII, Major Medical Expense. POLICY PROVISIONS Entire Contract; Chan�es: This Poli.cy (including the endorsements and attached papers) the application of the Policyholder and the individual appli_cations, i.f any, of the persons insured hereunder, constitute the entire contract between the parties. All statements made by the Policyholder or by any of the Insured Persons shall be deemed representations and not warranties, and n� such statement shall avoid the insurance or reduce the benefits under this Policy or be issued in defense of a. claim hereunder unless it is contained in a written application. No change in this Policy shall be valid until approved by an exECUtive offic,er of the Company and unless suc.h approval be endorsed hereon or attached hereto. No agent has authority to change this Policy or to waive any of its provisions. ' Grace Period: A grace period of 31 days will be granted for the payment of premiums accruing after the first premium, during which grace period the Policy shall continue in force, but the Policyholder shall be liahle to the Company for the payment of the premi.um accruing for the period the Policy continues in force. Notice of Claim: Written notice of claim must be given to the Company within 30 days after the occurrence or commencement of any loss covered by the Policy, or as soon thereafter as is reasonably possible. Notice given by or on behalf of the Insured Person to the Company at fts Home Uffice in the City of Saint Paul, Minnesota, or to any Branch Office of the Company, or to any author.ized agent of the Company, with information sufficient to i.dentify the Insured Person shall be deemed notice to the Company. Claim Forms: The Company, upon receipt af notice of claim, will furnish to the claimant such forms as are usually furnished by it for f.iling proofs of loss. If such forms are not furnished within 15 days after the giving of such notice, the claimant shall be deemed to have complied with the requirements of this Policy as to proof. of loss upon submitting, within the time fixed in this Policy for filing prooFs of loss, written proof covering the occurrence, the character and the extent of the loss for which claim is made. Proofs of Loss: Written proof of loss must be furnished to the Company at its said oflice 90 days after the date of such loss. Failure to furnish such proo£ within the time required shall not invalidate nor reduce any claim if it was not reasonably possible to give proof within such time, pravided such proof is furnished as soon as reasonably possible. `iiirfe c� P�;--��-<- � ''.aim: Indemnities payable under this Policy for any loss will be paid immediately upon receipt af due written proof of such loss. Payment of Claims: All indemnities payable• under. this Poli.cy will be payable to the Insured Person and any accrued indemnities t.inpaid at the Insured Person' s death will be payable to the estate of the Insured Person. - 1� - Assignment: No assignment of interest under this Policy shall be binding upon the Company unless and until the original or duplicate thereof is received at the Home Office of the Company, which does not assume any responsibility for the validity thereof. Physical Examinations and Autopsy: The Company at its own expense shall have the right and opportunity to examine the person of the Insured Person when and so often as it may reason- ably require during the pendency of a claim hereunder and to make an autopsy in case of death where it is not forbidden by law. Legal Actions: No action at law or in equity shall be brought to recover on this Policy prior to the expiration of 60 days after written proof of loss has been furnished in accordance with the requirements of this Policy. No such action shall be brought after the expiration of 3 years after the time written proof of loss is required to be furnished. Certificates for Insured Persons: The Company will issue to the Policyholder for delivery to each Insured Person, an individual certificate setting forth a statement as to the insurance protection to which the Insured Person is entitled and to whom indemnities pro- vided by this Policy are payable. Clerical Error: Clerical error upon the paft of the Policyholder shall not prejudice the insurance of any Insured Person nor shall such error continue the insurance of any Insured Person beyond the date it would otherwise terminate under the terms of this Policy except for such error. Conformity with State Statutes: Any provision of this Policy which, on its effective date� is in conflict with the statutes of the state in which this Policy was delivered or issued for delivery is hereby amended to conform to the minimum requirements of such statutes. Not in Lieu of Workmen�s Compensation: T'his Policy is not in lieu of, and does not affect any requirement for coverage by, Workmen's Compensation Insurance. Specifications Govern: Nothing herein contained shall limit or reduce any of the provisions contained in the original specifications and agreement, a copy of which are attached hereto and made a part hereof. If there are any terms, phrases or provisions contained herein that may be contradictory to the aforesaid agreement and specifications, the language of the agreement and specifications shall have precedence. PROVISIONS REQUIRED BY LAW TO BE STATED IN THIS POLICY: - "This Policy issued under and in pursuance of the laws of the State of Minnesota, relating to Guaranty Surplus and Special Reserve Funds." Chapter 437, Generai Laws of 1909. IN WITNESS WHEREOF, the ST. PAUL FIRE AND MARINE INSURANCE COMPANY has caused this Policy to be signed by its President and Secretary, but the same shall not be binding upon the Company unless countersigned by a licensed resident agent of the Company. �:�Wu-- �. ��"`�-� ' � Pre.ridcnt. Setretary. Countersigned by Licensed Resident Agent - 11 - . � . .._,. � . .,.. .,..�.... ....».......r�.+ri1;.:WCy PREMIUM SCHEDULE When the Insured Person's insurance becomes effective on or before the 15th day of a month, a full monthly premium shall be charged for the fraction of such insurance month. When the Insured Person's insur��nce becomes effective after the lSth day of a month, no premium snall be cl�arged for the remainin� fractional part of that insurance month. Premiums required to be paid by the ?nsured Person may he paid only by deduction from the Policyholder' s payroll, except as otherwise specifically provided in the Policy. The monthly premium due the Company on the lst day of each month for the insurance pro- vided in the Policy to which tliis Premium Schedule is attached shall be calculated at the rates set forth below; Part I - Monthly Benefit for Total Disability (Insured Person Only) ' Monthly Monthly Premium Benefit Rate $100.0� $ 3.08 120.00 3.68 140.00 4.28 200.00 6.12 300.00 9. 18 Part II - Surgical Expense Cxcept on Account of Pregnancy; and Part III - Obstetrical Expense; and Part IV - Anesthetist Expense; and Part V - In-Hospital Medical Expense; and Part VI - Accident First Aid Treatment at Clinic or poctor's Office or at Hospital as an Out-Patient. Employee (?nly $ 1.30 Employee and Dependents 4.35 Part VII - Diagnostic Procedure Expense Employee Only $ �75 Employee and Dependents 2.00 Part VIII - Major Medical Expense I:mployee Only $ 3. 10 F.mployee and Dependents 10.55 , .� Form No. 12320 PS _Ed. 11-69 POLICY N0. CEU 921 RETIR�ES GROUP ACCIDENT AN� SICKNESS POLICY A CAPITAL STOCK COMPANY T�� JT, PAIJL ST. PAUL FIRE AND MARINE INSURANCE COMPANIES INSURANCE COMPANY �:� �f�� ` �� -<�� 9 x��,_ �-�� ST. PAUL, MINNESOTA '"�,�`��'��,� (Herein called the Company) Serving you around!he wodd...around tha clotk The Company agrees with the Policyholder named `in the Schedule (herein called the Policy- holder) to pay benefits to the extent herein provided as to each person insured (herein called the Insured Person) for loss resulting from (1) accidental bodily injuries occurring to any Insured Person or cover.ed dependent spouse which are the direct and independent cause of the loss (herein called such injuries) or (2) sickness or disease contracted by the Insured Person or covered dependent spouse (herein called such sickness), subject to the provisions, conditions and exclusions of this Policy. SCHEDiJLE I'olicyholder's Name and Address Cit of St. Paul St. Paul Minnesota 55101 Effective Date%� Term Januar 1 1970 12 T4onths -` 12:01 A. M. , Standard Time, at the address o£ the Policyholder. This Policy is issued in consideration of the application of the Policyholder� copy of which is attached to and forms part of this Policy, and of the Payment by the Policyholde.r o£ the premium on behalf of each Insured Person at the rates set forth in the Premium Schedule, to take efiect on the date indicated in the Schedule, from which date all insurance years and months shall be calculated, and for the Term indicated in the Sch.edule. R�NEIdAL This Policy may be renewed for further consecutive terms by the Policyholder at the Company's premium rates in effect at the time of each such renewal. The Company reserves the right to establish on any anniversary date of this Policy new premium rates, provided the Company gives written notice to the Policyholder of such new premium rates at least 120 days prior to the anniversary date at which such new premi_um rates will become effective. ELIGIBILITY Each former employee of the Policyholder (age 65 or over) who has retired on or before December 31, 1969 and who is presently insured under Policy CEO 921, Ed. 7-b6, as a retiree will be eligible for insurance hereunder on January 1, 1970. Such eligible person will be eligible to insure with respect to his or her dependent spouse (age 65 or over) on January 1, 1970. An employee of the Policyholder (age 65 or over) who retires on January 1, 1970, or later will be eligible for Chis insurance on the day their insurance as an active employee ter- minates. Such eligible employee is also eligible to insure with respect to his or her dependent spouse (age 65 or over). Form No. 16245 RGP Rev. 11-69 EFFECTIVE DATE OF INDIVIDUAL T_NSURANCE Each person eligible for insurance under this Policy will become insured on the day of their eligibility. The effective date of a person's i.nsurance with respect to his or her spouse shall be the effective date of such person's insurance. BENEFITS When the Insured Person or covered dependent spouse as the result of such injuries or sickness, (a) shall incur expense for �vhich payment is or would be provided for under Part B Supplementary Medical Insur_ance Benefits for the Aged, of Title XVIII o£ the United States Social Security Amendments of 1965, the Company will pay 80% of such expense in excess of any amounts the Insured Person or dependent spouse is or would be entitled to receive under said "Part B", whether or not such person or spouse is enrolled thereunder; or (b) shall incur expense for out-of-hospital drugs and medicines requiring a doctor's prescription, the Company will pay 80% of such expense. Sections (a) and (b) of this provision, in the aggregate, shall be subject to a $50 calendar year cash deductible and the �Lifetime Aggregake Amount payable for all periods of treatment for all such injuries or such sickness shall not exceed $10,000, and provided always that of such Lifetime Ag�regate Amount, no more than $2,500 shall be payable for all periods of treatment of nervous or mental diseases or deficiencies, psychotic or psychoneurotic dis- orders or renctions. v No benefi.ts will be paid hereunder to the extent such benefit payment duplicates any benefits payable under Group Accident and Sickness Policies CEO 920 and/or 922. EXTENDED COVERAGE Should the insurance with respect to the Insured Person, or a dependent spouse of the Insured Person, terminate for any reason except payment of the $10,000 Lifetime Aggregate Amount, coverage for such person whose insurance terminated will be extended in the event the person is totally disabled (unable to perform the duties of any occupation for wage or profit, or if they have no occupation,- the inability to perform substantially all of their normal activities) at the time of such termination but such extension of coverage will apply solely to the accident or sickness which caused the total disability and then only during the period of such total disabilfty and while such person is under the care of a doctor, but not beyond � the end of 12 months following the date such termination occurs. EXCLUSIONS Anything in this Policy to the contrary notwithstanding, the insurance hereunder shall not cover: (a) intentionally self-inflicted injuries, or suicide or any attempt thereat, while sane or insane; nor (b) expenses incurred for treatment or while confi.ned (1) in a state hospital as a non-paying patient or in a federal or Veterans �dministration hospital� or (2) at the direction of. the Veterans Administration as a non-paying patient; nor - 2 - _ . . _ , . ..., . .,. .. .,u...,,....�.,,�...,.......�.......� (c) acci.dental bodily injuries (1) occurring while operating, learning to operate, or serving as a member of the crew of any aircraft, or (2) which are the result of or caused by any act of waz, insurrection, or participation in a riot; nor (d) accidental bodily injuries or sickness for which the Insured Person or covered dependent spouse is entitled to benefit under any Workmen's Compensation, Fmployer's Liability, Occupational Disease or similar law or act. T�RMINATION OF INDIVIDUAL INSURANCE The insurance of any Insured Person shall termi.nate automatically in the event: (a) such person is paid the $10,000 Lifetime Aggregate Amount; or (b) the Policy is terminated; or (c) the requi.red premium payments cease to be made by or on behalf of the Insured Person. The insurance of an Insured Person's dependent spouse shall terminate automatically in the event: (a) such person is paid 'the $10,000 Lifetime Aggregate Ar,iount; or (b) the Policy is terminated;� or � (c) the required premium payments cease to be made; or (d) the person ceases to be a dependent spouse. MONTHLY PREMIUM STATEMF.NT The Company will send to the Pol.icyholder a monthly premium statement. The Policyholder will furnish on the Company's forms such information relati.ve to new Insured Persons insured and terminations of insurance as is necessary to enable the Company to prepare such premium statements. If any such information is received too late for the changes to be included in the current premium statement. proper charge or credi.t therefore will be given in a succeeding premium statement. PREMIUM PAYMENTS All premiums for insurance hereunder, except as otherwise specifically provided, are payable solely by the Policyt�older to the St. Paul Fire and Marine Insur<�nce Company, St. Paul, Minnesota on or before the dates upon which they fall clue. TERMINATION OF POLICY Al1 insurance under thi.s Policy shall terminate at the end of the grace period when the requi.red premium is not paid. The insurance of every Insured Person, including insurance with respect to his dependent spouse, shall immediately cease upon discontinuance of this Polic}�, pr.ovided, however, that such termination shall be without prejudice to any claim originating prior thereto. The Policyholder may terminate this Policy on any premium due date. - 3 - POLICY PROVISIONS Entire Contract; Changes: This Policy (including the endorsements and attached papers) the application of the PolicyhoLder and the individual applications, if any, of the persons insured hereundcr, constitute the entire contract between the parties. All statements made by the Policyholder or by any of the Insured Persons shall be deemed representutions and not warranties, and no such statement shall. avoid the insurance or reduce the benefits under this Policy or be i.ssued i_n defense of a claim hereunder unless it �.s contained in a written application. No change in this Policy shall be valid until approved by an executive officer of the Company and unless such approval be endorsed hereon or attached hereto. No agent has authoriCy to change this Policy or to waive any of its provisions. Grace Period: A grace period of 31. days will be granted for the payment of premiums accruing after the first premiu�r►, during which grace period the Policy shall c�ntinue in force, but the Poli.cyholder shall be liable to the Company for the payment of the premium accruing for the period the Policy continues in force. Notice of Claim: Written notice of claim must be given to the Company within 30 day, after the occurrence or commencement of any loss covered by the Policy, or as soon thereaft=er as is reasonably possible. Notice given by or on behalf of the Insured Person to the Company at its Home Office in the City of Saint Pau1, Minnesota, or to any Branch Office of the Company, or to any authorized agent of the Company, with information sufficient to iclentify the Insured Person shall be c�eemed notice to the Company. Claim Forms: The Company� upon receipt of notice of claim, will furnish to the claimant such forms as are usuall.y furnished by it for filing proofs of loss. If such forms are not furnished within 15 days after the giving of such notice, the claimant shall be deemed to have complied with the requirements of this Policy as to proof of loss upon submitting, within the time fixed in this Policy for filing proofs of loss, written proof coveri.ng the occurrence, the character and the extenC of the loss for which claim is made. Proofs of Loss: t�ritten proof of loss must be furnished to the Company at its said office 90 days after the date of such loss. Failure to furnish such proof within the time required shall not invalidate nor reduce any claim if it was not reasonably possible to give proof within such time, provided such proof is furnished as soon as re.asonably possible. Time of Payment of Claim: Indemnities payable under this Policy for any loss will be paid immediately upon receipt of due written proof of such loss. Payment of Claims: All indemnities payable under this Policy will be payable to the Insured Person and any accrued indemnities unpaid at the Insured Person's death will be payable to the estate of the Insured Person. Assignment: No assignment of interest under this Policy shall be binding upon the Company unless and until the original or duplicate thereof is received at the Home Office of the Company, which does not assume any responsibility for the validity thereof. Physical Examinations and Autopsy: The Company at its own expense shall have the right and opportunity to examine the person of the Insured Person when and so often as it may reasonably requixe during the pendency of a claim hereunder and to make an autopsy in case of death where it is not forbidden by law. Legal Actions; No action at law or in equity shall be brought to recover on this Policy prior to the expiration of 60 days after written proof of loss has been furnished in accordance with the requirements of. this Policy. No such action shall be brought after the expiration of 3 years after the time written proof of loss is required to be furnished. - 4 - Certificates for Insured P�rsons: The Company will issue to the Policyholder for delivery to each Insured Person, an individual certificate setting forth a statement as to the insurance protection to which the Insured Person is entitled and to whom indemnities provide� by this Policy are payable. Clerical Error: Clerical error upon the part of the Policyholder shall not prejudice the insurance of any Insured Person nor shall such error continue the insurance of any Insured Person beyond the date it would otherwise terminate under the terms of this Policy except for such error. Conformity with State Statutes: Any provision of this Policy which, on its effective date� is in conflict with the statutes of the state in which this Policy was delivered or issued for delivery is hereby amended to confor.m to the minimum requirements of such statutes. Not in T,ieu of Workmen's Compensation: This Policy is not in lieu of, and does not affect any requirement for covera�e by, Workmen's Gompensation Insuranc.e. PROVISIONS REQUIRED BY LAW TO BE STATED IN THIS POLICY: - "This Policy issued under and in pursuance of the J.aws of the State of Minnesota, relating to Guaranty Surplus and Special Reserve Funds." Chapter 437� General Laws of 1909. IN WITNESS Wf{EREOF, the ST. PAiJL FIRE AND MARINE INSURANCE COMPANY has c.aused this Policy to be signed by its President and Secretary, but the same shall not be binding upon the Company unless countersigned by a licensed resident agent of the Company. , \�-(.tJu- 0«, WU��^'�-, Secretary President Countersigned by Licensed Resident Agent - 5 - PREMIUM SCHEDULE The monthly premium due the Company on the lst day of each month for the insurance provided in the Policy to which this Premium Schedule is attached shall be calculated at the rates set forth below: Insured Person $ 3.00 Insured Person and Dependent Spouse $ 6.00 Form No, 16245 PSR Ed. 11-69 CEO 922 EARLY RETIREES NON-OCCUPATIONAL GROUP ACCIDENT AND SICiQVESS POLICY A CAPITAL STOCK COMPANY T�E ST. PAUL ST. PAUL FIRE AND MARINE �NSURANCE COMPANIES INSURANCE COMPANY � � ��f?� .';. ST. PAUL, MINNESOTA �'g �� (Herein called the Company) Serving you aiaund!he world..,around!he clock SCHEDULE Policyholder's Name and Address Cit of St. Paul St. Paul Minnesota 55101 Effective Date* Term Januar 1 1970 12 Months * 12;01 A. M. , Standard Time� at the address of the Policyholder. The Company agrees with the Policyholder named in the Schedule to pay benefits to the extent provided as to each person insured (herein called the Insured Person) for loss resulting from (1) accidental bodily injuries occurring to any Insured Person or covered Dependent which are the direct and independent cause of the loss (herein called such injuries), or (2) sickness or disease contracted by the Insured Person or covered Dependent (herein called such sickness) subject to the provisions, conditions and exclusions of this Policy. This Policy is issued in consideration of the application of the Policyholder, copy of which is attached to and forms part of this Policy, and of the payment by the Policyholder of the premium for each Insured Person in the manner and at the rates set forth in the attached Premium Schedule, to take effect on the date indicated in the Schedule, from which date all insurance years and months shall be calculated, and for the Term indicated in the Schedule. RENEWAL This Policy may be renewed for further consecutive terms by the Policyholder at the Company's premium rates in ef£ect at the time of each such renewal. The Company reserves the right to establish on any anniversary date of this Policy new premium rates, provided the Company gives written notice to the Policyholder of such new premium rates at least 120 days prior to the anniversary date at which such new premium rates will become effective. Form No. 12320 ERP Ed. 11-69 __�.,_^....,_......_..,,.___._...... . . • Part I SURGICAL �XPENSE rXCEPT ON ACCOUNT OF PREGNANCY The Company will pay indemnity in the amount of the expenses incurred for a surgical pro- cedure performed by a Doctor upon the Insured Person, or covered Dependent, because of sdch injuries or such sickness, except pregnancy, but not exceeding the Maximum Amount specified for the applicable surgical procedure in the Schedule of Surgical Procedures. For any surgical procedure not specified in the Schedule of Surgical Procedvres the Company will determine the indemnity payable 'based on a surgical procedure of equivalent gravity and severity. The maximum indemnity payable for all such surgical procedures performed upon the Insured Person or each such covered Dependent because of any one accident or sickness is $200.00. When more than one surgical procedure is performed during the course of a single operation, indemnity in the amount of the expenses incurred for each such surgical procedure shall be payable, but the maximum aggregate indemnity payable for all such surgicaL procedures shall not exceed $200.00. Provided always that no indemnity shall be payable under this Part II when the amount payable under Part V of the Policy for visit(s) for treatment(s) by a Doc.tor made on and after the day surgical procedure(s) is performed would exceed the amount otherwise payable for the ' surgical procedure(s). Part II OBSTETRICAL EXPENSE The Company will pay indemnity in the amount of the expenses incurred for an obstetrical procedure named in the Schedule of Obstetrical Procedures performed by a Doctor upon the Insured Person, or dependent wife of the Insured Person when covered hereunder, because of a Pregnancy but not exceeding the Maximum Amount specified in such schedule. Provided always that no benefit shall be payable (a) for an obstetrical procedure performed upon the Insured Person unless the Insured Person was insured for Dependent coverage con- tinuously since the commencement of the Pregnancy, or (b) for an obstetrical procedure performed upon the dependent wife of the Insured Person unless ttie Pregnancy commenced while the insurance with respect to such dependent wife was in effect. SCHEDULE OF QBSTF,TRICAL PROCEDURES Maximum Description of Obstetri.cal Procedures Amount Caesarean Section, including delivery of chi.ld or children. . . . . . . . . . . $100.00 Pregnancy, delivery of child or children (all types except Caesarean) . . . . . . 50.00 Pregnancy, ectopic (also ruptured). . . . . . . . . . . . . . . . . . . . . . . . 125.00 Pregnancy, before seven (7) months, including dilatation and currettage if necessary . . . . . 30.00 Only one payment, the larger applicable thereto, shall be made on account of any one Pregnancy. - 2 - SCIi�DULE OF SURGICAL PROCEDIIRES EXCEPT ON ACCOUNT OF PREGNANCY T`he amouats stated in this Schedule do not or are not intended to fia or govern the fees charged for performing surgical procedures. Maxi- Maxi- Description m� De.scriptioa m� of Surgical Procedure Amount of Surgical Procedure Amount ABDOMINAL SURGERY For compound fractures the maximum surgical pro- Abdomen� paracentesis...... .... .. .... ........ $ 13.35 cedure expense benefit will be one and one-half Appendectomy..... ...... ............. . 133.35 times the amount shown above for the conespond- Appendiceal abscess��drainage.............. .... 100.00 ing simple fracture. For fractures requiring an Cholecystectomy............. .......... . ... .. 180.00 open operation or skeletal traction,the maximum Cholecystotomy.............. ...... .... ...... 133.35 surgical procedure expense benefit will be twice Colostomy................. .. .... ...... . . .... 133.35 the amount shown above for the conesponding Common duct� surgery...... .. .. .. .. .. ... . .. .. 200.00 simple fracture, but not to exceed $200.00. Diverticulum� iatestinal.... . . . . .. . . . . .. . . .. .. 133.35 pI.thopedic Gastrectomy� total or partial. . . .. .. .. . .. . . .. . . 200.00 Arthroplasty, any major joint............. .... . 200.00 Gastro-enterostomy............ .. .... . .. .. .. .. 180.00 Bone graft (long bone)... .... .. ........... .... 200.00 Herniotomy, diaphragmatic....... .... ... .. .. .. 133.35 gunion operation.. ... .. .. . .. . ... .. ...... .... 46.65 Herniotomy, single. ....... ........... ...... 100.00 Coccyx, excision of. . .. . ... .. 46.65 Herniotomy� bilateral................. .... .. .. 166.65 �,Zanipulation of joint(s) for adhesions (regazdless Intestines� anastomosis........................ 133.35 of number). . ...... ................ 33.35 Intestines. resection. . . . . .. ......... .. .. .. .. . . 200.00 Osteomyelitis� drilling bone cortex..... .... .... . 80.00 Intussusception, operative reduction............ �166.65 Spi�a1 fusion. . . . . . .... ...................... 200.00 Laparotomy� eaploratory................ .... .. 100.00 Tenorrhaphy. . . .. ... .... .... ................ b6.65 Pancreas, drainage. . .................. .. 166.65 Tenotomy.. .. . . .. ....... .................... 33.35 . . . .. . Peptic ulcer, perforated, closure.............. .. . 133.35 EAR, NOS�, AND THROAT SURGERY . Splenectomy..... . ....... ............. .. ... . . 200.00 Antrumpuncture...................... ...... 6.65 Antrum window...... .. .. ...... ...... ... . 33.35 BONE, JOINT, AND TENDON SURGERY Laryngectomy. . . . .. . ... .............. .. Z�•� Amputations b2astoidectomy, simple..... . .................. 133.35 lpp,pp Mastoidectomy, radical. . 2�•� Arm., ... ....... .................. ... 20.00 Nasal polyps, removal, unilateral..... ...... .... 20.00 Fingerortoe. . . ........... ............ .... .. .... .. .... .. Hand or foot. . . . . ... ...... .... ............ .. 66.65 Nasal polyps, removal, bilateral.... . ........... 33.35 200,pp Paracentesis tympani.. 6.65 Hip..... .. ... . .. .. ... ... .............. .. Submucous resection..... .. ........ .. ... .. .... 66.65 I.eg, at or below knee...... ............. .... .. 113.35 . .. ....... ...... .. .... Shoulder. ... ... ..... ........ .. .. ...... .. .. .. 166.65 Tonsillectomy or tonsillectomy and� Thigh.... .. . . . . . .. .. ... . .. .. .. .. .. .. . . .... .. 133.35 adenoidectomy....................... ...... 33.35 Dislocations-Uncomplicated Tracheotomy. .. .. .. ... ............. ... ...... 46.65 Elbow.. .. ... .... ...... .. .. .. .. .. .. ........ � 33.35 Turbinectomy. . . . ... .. .. .. ...... ...... . ... 13.35 Finger or toe. . . ..... .. . . . .... . .... .... .. .... 6.65 EYE SURGERY Hip............... .. . . ......... ..... .. .. .... 66.65 Cataract, needling... .. .. . . . . 33.35 Knee. ... .. .. .. .... 40.00 Cataract� removal...... .. .. . . . . .. .. . ... .. . .. . 133.35 Knee� semi-lunar�cartilage�requiring Chalazion. . ... .. .. .. .. . ... .. .. .. .. .... . ..... 6.65 open operation........... .. . . . ... ...... .... 133.35 Entropion or ectropion. plastic operation. . .. . . .. 80.00 Mandible. . . . . ..... .... . ..... ... ...... .. .... 6.65 Enucleation or evisceration........... . . ... .. $100.00 Shoulder. .. .. ... .. .. .. .. ....... .. ..... .. .... 20.00 Foreign body, removal from cornea or sclera... . . 6.65 Spine...... ..... .... ... . .. .... .. . .. ... .. .. .. 133.35 Lachrymal sac, removal or dacrocystorhinostomy.. 66.65 Fractures-Simple Pterygium..... .. ...... .. .... .. .............. 40.0(1 Carpal or tazsal bone, one (except os calcis or GYNECOLOGY astragalus). . ... .. ............. .... .. .... 33.35 Bartholin's gland or labial cyst, eacision.... . .. 40.00 Clavicle or scapula. . .... ................. .... 33.35 Carcinoma of the cervix-complete treatment.... 200.00 Femur or hip. .. ..... ........................ 133.35 Cauterization of cervical canal with conization. .. 33.35 Finger or tce. . . ......... .............. ...... 13.35 Cauterization of exo cervix. ........ . ... ..... .. 6.65 Humerus.. ... . .......... .......... ..... . .... 100.00 Colporrhaphy� anterior.... . ... .. .. .. .. .. .. 66.65 Mandible. ............ . . . . ................ 66.65 Combined cervical and cystocele or Metatazsal or metacarpal bone� one. . . . .. ...... 20.00 perineal repair. .. .... . .. . . .. . . . .. . . . 100.00 Nose....... . ........ ........................ 20.00 Dilatation and curettage, except as complication Olecranon. .. . . ... . ..... . .. ........ .... ...... 46.65 of pregnancy.. .. .... .. . . .. ..... . . 33.35 Patella... .. . . ...... .. . . .. .. .. .. .. . ....... 66.65 Fistula, vesico-vaginal or rectavaginal..... ..... 133.35 Pelvis (coccyz�xcepted).. ....... ........ 133.35 Hysterectomy, subtotal. . ... . . .... .... ... .... . 166.65 Radius and ulna involving shaft........ ...... .. 66.65 Hysterectomy� total. .. . ............ .... . . 200.00 Radius or ulna or Colles' fracture............... 46.65 Oophorectomy and/or salpingectomy. . ......... 133.35 Rib, one or more.. ....... . . ... . . . ...... ...... 13.35 Perineorrhaphy, including rectocele............. 66.65 Spine, compression fracture.. . ... .. ......... . 133.35 Trachelorrhaphy. .... .... ..... .. ......... . . 33.35 Tibia and fibula except Pott's fracture........ .. 100.00 Uterine polypi, removal. .... . . ...... ...... .. .. 33.35 Tibia or fibula including Pott's fracture......... 66.65 Uterine suspension. . . . . .... .. .. .. .. .... .. .... 133.35 19223 RHS Ed. 8-69 00'i� ''''''''IIOZ;aalat q�sa ';o noT��a[ui 'suian aso�u�eA 00'OOI ''''''•''' ••:•�.Ia�s�q 'ucan snouaqd�es 'uoi��iZ S9'99 .. ............apis auo 'uian snouaqd�s 'uot��iZ S9'99 ...... .. .. .. . ... .. . .. .. . . . . . .�tcuo3�aia�o�ueA tnaA aso�usA S9'99I ........ . . .. .. ... . .... ..... .�Ctuo�oq�ii-oia�asn 00'OOZ ... ..... ..... .. ... .. .... .�3� '�iuzo��aptoi�iqy S9'99I ...... ...... . ... . . �iq�amsusi�..�icuo3�a��sosd S£'££I .. . ... ...... .. .. ......I'�'1o�•qns '�uio��a ioi�C 00 OOZ •I�auuad ao a�a druo� �i�se do�ssou� ��3$ om� io auo `�iqndeidns '�iuzo��a3s�soad 00'OOZ ................. .. . .� i ) I u.L S9'99 .. ........ .. .... .... . . . . .... ....,�vuo��apiq�sp S9'9 .............. .. ....�a `Sii�a 'x�eiou;oumaud 00'OOZ ... ... ... . . . . . .. . . . . . .. . .. .. .. ...�ituo�oiudaN 00'OZ .............. .. . ... .uoi��npui 'x�iou�oLUnaud 00'OOZ ......... . .. . . .. .. . . . . . . ... .. . . ..�LUO��aiqdaN S9'9 ................... .... . . .scsa�ua�EiEd `�maid .......... .... ... . 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"5aect�on B, f�fec�t.an.`B�.n�#;s . . .,.,. ,. : . . .: , 17) T6�'rs provtsion.sh;al!sa�ply'i� d�t�rmiritt,fg 1�I�tt�; ben�!f'r4s is�,� t6s,a��rson.ap-y��l�nd�r Y�!is 4?Icn �r,4ny,Cfctun ��e.r,mi- rozmtiaei �Period i#,.`is�r►�iie:�tifil��ts�ble..E�ae�ses 'in�urr�1 ps�#o�ticli ;p�:ersan ,�l��ng!:;yt�h ,peribd;;the sui� c�fi 4�' th�i b�e�€ts tirafi�v�ou�d��e per�able urtt��r,xti�s ?loci ;n�►�e`:ct�senC��of t�i� P�c��!�iR+�,, and : . ,;,�. _ m , .; ; (bj th�bet�►efi�,t�xat �wo�1Fd�s;�:a�rssfi4e urt�l�r akl o�er P.ia�!� i� ths absence �#�er�kn dF�rr,�!i�ts aF.�!g�Miq+' �,.c�r,pose .to�tkis pR�WC�n . , ti - ,. ,;� . , " . . ,;:.t wauld'ieiiceetl`sn.cf�� Alrcr�n,i�r4��xp.etzs.r.a. , ' -. '•` � �' ; ,;' , : - ' � � .�. . , • ,, ` ._ ., ,�.. .:, `, � • : ('�;As�p ose�y,ClArm'%I�ei#ermi�t4`rs�n P,eaiQd .»;iith.r.�9�ect tc� wh�ch;fhis provisi+Qn ;is applicable,�tEue be�k�s;lkt�tt w�uld �e ' '�' nbke�t�nd�r.t ax PEmn in4tt,e aiasertce wf this.provis�fln fbr fhe Allo.�pble;� ' . . P�K �1� . , Xpens,e� i�curred t�s�to�uch.{�;�rsqq,ducinc� ;suCh�tGi'aiiri D.e.te�mincfFian':F'erimd shall be:r.ediuced ,to the;exte�rt:t�ecessary yo��t�at the s,u+n cr# su��;r.Qd�etd �en�ts � , ;nnd alf?ffie'b�n�its pmysr6le ,fc�r such �411�wc��te`Expgnses,urrd�r qll ather P,�ans, except as Pro�iderd in;F#em e(;�,) of�tk�is � ,:.` ' �_ Ss�#ion�, shall nat eacca�:d'fhe,total of�th.+�Al�av�m:ble�fxpenses. •B,enefits payable ,u��r anqther .A,4pfi inclttd,e the �"` ,' �en�efts tthat vKmutB'hak�e .besn Epm,yabie ihad dlsaim`.be�n.�i.ul,y made .ther�for. , _ � -: - (�2 If . :: , (.q) cart�fher rPlxsn rwhich;is :in,v,sibred'in. item �.(?�{ Qf fih"ts S�ction B 'and Nihich cont�i►rs .a ,�ravision��atordi�}fl� :its benefits wiNn tfhas�e�di this Plan�wou(t�,,ac�,qratng to its rules, determine:its bene°�if�,ai�r;�he,benefits o�f,�his�Aiqn ,, , hawe'besn cd�sterrrii�etl,,.art�! � ` :;(iy) ttre rukes s�t�fosth'iniitem:k.d)��ifrtfiis.5e�tictn B would Fequ�se this:?Iprt;to d�terr►tin�;its'be(�fiEs�he�fqr,e�,sNch other " ,Ftan � •then the f�en�f}ts;of:su�hcother;Plan .will:l�e'igrt�red`fior;th� purpo�es af det�fmi�tin� Fhe;,.6en§�fi�s ia+ti,dQr;this;Pkpn. ' (4) For the:{�urposes:of it.em+(�) af tNis`Secticm B, the ru�s establishing'phe ordec of:6e�efit cl�teimin9tion _c�-;e: (d) �tt.e berfefits,of xi�?lan.�Ph'tch;xo�c�rs;tl?e pe�rsQn:an .wfr9se e�pen:�:es tlai�n �,s�base�'.oth�r,tFkqn .c}s,ya depe�►dent shaU be d.cte�rrtiirted 6efore�tfie benefits s�f a�PIaR wk�iGfi :�c�vers suth p@cson �s,p.,�peR¢�nt; (b) The benefits of�a fitan vtiiich ccaver.,s tfie:person on w#�ase ex-pens�s r<Ic�im is _based .qi,a';d��ent,qf,a.�nale person shall be=determine;d 6�fo[ertt�e�benefits.flf a PiAn which �overs s4ch:p�gc,son as,� c�epende�t of a female �zerson; (c) Wf�en r.ulesifa) artzl (fi).dn�nqt.establish�an order;qfbgnefit,deter�riinqtipn, th��bsn�fjl,s of,a Rlp�,y�hjt��has cov- ere.d thQ.�ers.on�on.v�hQSe:.ex�enses�claim is bose�i for:the loirger period,of time shall be deteuFnir�ed before the benefits of:a;�'!an wtii¢ti'fias;.covered-su:eh Rerson the shorter period Qfrtime. Section C. �Rig}i#�t.o Receive an,d Release NeFes,s4ry Inforrttation For the purposes of determinin�g the,appl�ability•qt and implemenrinc� the. terrns of`,'this prov�is9n'of this Plan or any provision af similar purpose�of any other;EP�at�,rt.he�Compuny rr�ay,without the conseRt,of,or;�ofice,to any person, release to or obtain from'any other insurance cotr�pony or oftaer organization or person any':inforc,n�tion, with respect to any person, which the Company deems to be nec�ssary.for such purposes. Any person claimi�:g benefits under this Plan shall furnish to the Company such information as may be necessary to implemenf this provision. 16094 NBP Rev. 11•69 Printed in U.S.A. (over) i ' ��:�'�Sr`,c� ��'.��;�� 3��!b�� cr-;�t► `'�� 1n��'°1s •su�i;�zius�i�,�: '"�'�E�� ;��__ `�� o�� u,:�� as _,� �_� ;�� F��°� :�_ �,-��a�ap Una�s .�ucadwo� ay� so '�iwMO� �y} � a��e �� ;�u� ��:z��aa� �a�,�:� ��,.x��e� ��,� < <��°��gx� �� j °s� ��aA f,.� e;;.��s: �a�oaa.� oy �y6u ay� an�4 Itoys �(uod -^��r ��, ay� ��^�i,�� i ��yy��ua��ai �`�l_+f�,ss�c�� 4�:��yt; <.� ��o�t�sa��u ��,.�ar��A.s�� ,� ��anowo wnwixow ay� ;a ssa�xa us 'awi� �.�y ,;� `�urt._�:_-n v,��CM o ud �asu�dx� �pq�en��p�� ,�z,� Ro��i ,t��'us;�� a�, �e� �,�oeu �aaey a�b� s�uawK�d��anaua4M 1�.�,��os�� o ��:�� •� �oi��a�. � � ��,�.� �iy� s<�h�ur� /�i��e��.b urc-�^�. ��a�y�sip �(II^� �q Ilaays �CuA�wo� ay� �s�uaw -. �..,.7 �_;�ns ��a gu�. z� ��{d o; 'p�r�, ��:�d� o�d� `��ub� �.;F;� s �,„�uff y �� arF ,�ur,, -� ��,� ��cys pir�d os�.s�ur�ow4�p�n 'u�eisino�d siy� ��ar��gue yr,�:�son �� c�n .�a�.L�� us pa�l,��.�s�� r; c�$ aP.�p�::�aac-p Il�y� ta s:,ut�: .Rrr � _��. ��ua�v�(od �ay;o y�r�s fui��w suoi�oziun6�o �(4> �,,.�, �ano ��e� �,; r��s��b^a';� �;�_� .,�i �r ��«_ ��: ,�s �pqc,. �,��wxa '��:,ij �,�� ' �'a�W 16o�s �u�elwc� ay� 'ssen�d aay�o �(uo �apun a,:�r,� er�� ?� ��acu �e�gy9�or�i g�a�« ';�:� M�:;.��a�:��..;� �� z��d giar.P. Aap art a,��_�� =4aaq ann4 Plnoys y�iyen s�ua�u�(nd �anaua4M ��a��.A� �� (�il� �� °� �e;��ag EXTENDED COVERAGE A. Applicable to Parts I, TI, III, IV and V - When the Insured Person within 90 days immediately following termination of his insurance under this Policy, is confined in a Hospital or undergoes a surgical procedure, upon the recommendation of a Doctor� because of the same such injuries or same such sickness, except Pregnancy, which caused Total Disability beginning while such person' s insurance was in effect and conti.nuing until the date such confi_nement commences or sur�ic.al procedures is per- formed� the Company will recognize claim therefor in accordance with this Policy, provided (1) it would have been a valid claim had the insurance not terminated, or (2) termination of insurance is not due to the Insured Person reachi_ng age 65. ri. Applicable to Part III Only - When the Insured Person or dependent wife of the Insured Person when covered hereunder, within 9 months immediately follow.ing termination of insurance under this Policy with respect to such person, undergoes an Obstetrical Procedure on account of a Pregnancy whi.ch commenced while such insurance was in effect, the Company will recognize claim therefor in accordance with Fart III, provided (1) it would have been a valid claim had the insurance not terminated, (2) the termination was not due to failure of the Insured Person to make a required premium contribution while remaining eli.gible� and (3) termination of insurance is not due to the Insured Person or his dependent wife reaching age 65. SUCCESSIVE BENEFIT PERIODS Successive sur.gi_cal procedures or successive visit(s) for treatment(s) by doctor while confined in Hospital sha11 be considered as having occurred or having been required on account of one accident or one sickness unless they are the result of entirely unrelated causes or are separated by an interval of more than 3 calendar months. Benefits as provided hereunder shall be payable for either such injuries or sickness or pregnancy� but for not more than one during any one period of time. EXCLUSIONS Anything in this Policy to the contrary notwithstanding, the insurance hereunder shall not cover: (1) accidental bodily injuries arising out of or in the course of employment or sickness for which the Insured Person or covered Dependent is entitled to benefit under any Workmen's Compensation, Employers' Liability, Occupational Disease or similar law or act; nor (2) accidental bodily injuri.es sustained or sickness contracted by the Insured Person or covered Dependent while on active military or naval duty or which result from an act of war (declared or undeclared); nor (3) suicide or any attempt thereat while sane or insane; nor (4) intentionally self-inf�l.�cted injur.i�s;_ nor (,5) ��xpensps in�urred for treatment or while confined in a state hospital as a non-paying patient or in a Federal or Veterans Administration hospital or at the direction of the Veterans Administration as a non-paying patient; nor (6) dental surgery or dental work or dental treatment of any nature or eye examination or the fitting of gla.sses. _ ., No benef its will be paid hereunder to the extenC such b�n�f it paymPnt du�l f��:�t�:.s an;✓ }�enef its payable under Group Accident _�nd S,ickness Pol.�cies CF.� 9?0 and/or 921. _�� ._ �:; ELI�IBIL�TY The following employees will be pli�ible for insuranc� hereunder: (1) Each ;ernployee of the City of St. Pau1_ 's P�l�i�e cr Fi.rr nepaL�m�rit:s w��a avails-�- hims�lf .of_ early retirement, on or. af ter_ May 1, ?965, �ror,► ,*,h� �ify �f St. f�i�ul priq� �p reaching age, 65. ,Such empl4yeQ may 3?.sr, insu.re �.:itk� Fespect .t:a hi�-" Dep��d�ents. ;s; , , _ 4 _ EFFFCTIVE DATE OF INDIVIDUAL T_NSURANCE Each person eligible for insurance under this Policy will become insured on the day of their eligibility. The effective date of a person's insurance with respect to his or her spouse shall be the effective date of such person's insurance. BENEFITS When the Insured Person or covered dependent spnuse as the result of such injuries or sickness, (a) shall incur expense for which payment is or would be provided for under Part B Supplementary Medical Insur.ance Benefits for the Aged, of Title XVIII of the United States Social Security Amendments of 1965, the Company will pay 80% of such expense in excess of any amounts the Insured Person or dependent spouse is or would be entitled ta receive under said "Part B", whether or not such person or spouse is enrolled thereunder; or (b) shall. incur expense for out-of-hospital drugs and medic.ines requiring a doctor's prescription, the Company will pay 80% of such expense. Sections (a) and (b) of this provision, in the aggregate, shall be subject to a $50 calendar year cash deductible and the �Lifetime Aggregate Amount payable for all periods of treatment for all such injuries or such sickness shall not �xceed $10,000, and provided always that of such Lifetime Aggregate Amount, no more than $2,500 shall be payable for all periods of treatment of nervous or mental diseases or deficiencies, psychotic or psychoneurotic dis- orders or reactions. V No benefits will be paid hereunder to the extent such benefit payment duplicates any benefits payable under Group Accident and Sickness Policies CEO 920 and/or 922. EXTENDED COVERAGE Should the insurance with respect to the Insured Person, or a dependent spouse of the Insured Person, terminate for any reason except payment of the $10,000 Lifetime Aggregate Amount, coverage for such person whose insurance terminated will be extended in the event the person is totally disabled (unable to perform the duties of any occupation for wage or profit, or if they have no occupation,- the inability to perform substantially all of their normal activities) at the time of such termination but such extension of coverage will apply solely to the accident or sickness which caused the total disability and then only during the period of such total disability and while such person is under the care of a doctor, but not beyond the end of 12 months following the date such termination occurs. EXCLUSIONS . Anything in this Policy to the contrary notwithstanding, the insurance hereunder shall not cover: (a) intentionally self-inflicted injuries, or suicide or any attempt thereat, while sane or insane; nor (b) expenses incurred for treatment or while confi.ned (1) in a state hospital as a non-paying patient or in a federal or Veterans Administration hospital� or (2) at the direction of. the Veterans Administrakion as a non-paying patient; nor - 2 - . . . . ......W..y.r (2) Each employee of the City of St. P:�ul havin� not less than thirty (30) years of service wi.th the City of St. Patil and who is a member of any public employees retirement association covering City of St. Paul employees, and who retires� on or after December 13, 1967, from City of St. Paul employment after reaching age 58 but prior to reachin� age 65. Such employee may also insure with respect to his Dependents. EFFECTIVE DATE OF INDI��IDUAL AND DEPENDENT INSURANCE The effective date of the insurance of an eligible employee who makes written application shall be the effecti.ve date of this Policy or the first day of the month following the date of his retirement from em�loyment with the City of St. Paul. The effective date of an eligible employee's insurance hereunder with respect to a Dependent shall be the effective date of such employee's i.nsurance hereunder or the date he applies for such insurance, whichever is later. EVID�NCE OI' INSURABILITY Each eligible employee who applies for insurance hereunder with respect to himself or a Dependent more than 30 days after the eligibi.lity date shall be required to furnish evidence of insurability with respect to himself or the Dependent, as the case may be, satisfactory and without expense to the Company. TERMINATION OF INDIVIDUAL INSURANCE The insurance of the Insured Person shall terminate automatically at the end of the insurance month for which his prEmium was last paid and accepted by the Company in the event: (a) thi.s Policy is lapsed or discontinued; or (b) the required �remium payments cease to be made; or (c) khe Insured nerson reaches age 65. TERMINATION OF INSURANCE WITH RFSPECT TO DEPENDENTS The insurance of the Insured Person with respect to a covered Dependent shall terminate automatically at the end of the insurance month for which premium was last paid and accepted by the Company in the event: (a) this Policy is lapsed or discontinu�d; or (b) the required premium payments cease to be made; nr (c) the Insured Person's insurance terminates, except in the event of the Insured Person's demise; or (d) the Dependent no longer qualifies under the Dependent definition. - 5 - MONTHLY PREMIUM STATEMENT The Company will send to the Policyholder through its collecting agency, the Minnesota Mutual Life Insurance Company, a monthly premium statement. The Policyholder will furnish on the Company's forms such information relati.ve to new Insured Persons and termination of i.nsurance as is necessary to enable the Company to prepare such premium statements. If any such infarmation is received too late for the changes to be included in the current premium statement, proper charge or credit therefor shall be given in a succeeding premium statement. PREMIUM PAYMENTS A11 premiums for insurance, except as other.wise specifically provided, are payable solely by the Policyholder to the Minnesota Mutual Life Insurance Company, St. Paul, Minnesota, acting as collecting agency for the Company on or before the dates upon which they fall due. TERMINATION OF POLICY All insurance under this Policy shall terminate at the end of the Grace Period when the required premium is not paid. The insurance of every Insured Person, including insurance with respect to his covered Dependent(s), shall immediately cease upon discontinuance or termination of this Policy but without prejudice to any claim arising prior thereto. EXPERI�NCE RATING This Policy is subject to the Company's experience rating plan under which the Company may adjust the premium rates on any E'olicy anniversary date (subject to the requi.red notice hereinbefore provided) and, in addition thereto or in lieu thereof, the Company, at its option, may make a retroactive rate reduction for the previous policy year with a consequent refund of premium for that policy year payable in cash to the Policyholder. If, at any time, the aggregate amount of such refund exceeds the Policyholder's share of the aggregate amount of premium paid hereunder, such excess shall be applied by the Policyholder for the sole benefit of the insured employees. Payment of any refund to the Policyholder shall completely discharge the liability of the Company with respect to the refund so paid. No increase in premium rate shall be retroactive. CONVERSION PRIVILEGE When an Insured Person or his dependent spouse have been continuously insured under this Policy from the time of their eligibility until they reach age 65, the Company, upon receipt of notice from the Policyholder, will provide insurance under Policy CEO 921, Retirees Group Accident and Sickness Policy as presently constituted or later amended, at the Company's premium rates in force at the time of conversion. POLICY PROVISIONS Entire Contract; Changes: This Policy (including the endorsements and attached papers) the applicati.on of the Policyholder and the individual applications, if any, of the persons insured hereunder, constitute the entire contract between the parties. All statements made by the Policyholder or by any of the Insured Persons shall be deemed representations and not warranties, and no such statecnent shall avoid the insurance or reduce the benefits under this Policy or be issued �n defense of a claim hereunder unless it is contained in a written application. No change in this Policy shall be valid until approved by an executive officer of the Company and unless such approval be endorsed hereon or attached hereto. No agent has authority to change this Po�.icy or to waive any of its provisions. - 6 - Grace Period: A grace period of 31 days will be granted for the payment of premiums accruing after the first premium, during which grace period the Policy shall continue in � force, but the Policyholder shall be liable to the Company for the payment of the premium accruing for the period the Policy continues in force. Notice of Claim: Written notice of claim must be given to the Company within 30 days after the occurrence or commencement of any loss covered by the Policy, or as soon thereafter as is reasonably possible. Notice given by or on behalf of the Insured Person to the Company at its Eiome Office in the City of Saint Paul, Minnesota, or to any Branch Office of the Company, or to any authorized agent of the Company, with information sufficient to identify the Insured Person shall be deemed notice to the Company. Claim Forms: The Company, upon receipt of notice of claim, will furnish to the claimant such forms as are usually furnished by it for filing proofs of loss. If such forms are not furnished within 15 days after the giving of such notice, the claimant shall be deemed to have complied with the requirements of this Policy as to proof of loss upon submitting, within the time fixed in this Policy for filing proofs of loss, written proof covering the occurrence, the character and the extent of the loss for which claim is made. Proo£s of Loss: Written proof of loss must be furnished to the Company at its said office 90 days after the date of such loss. Failure to furnish such proof within the time required shall not invalidate nor reduce any claim if it was not reasonabl.y possible to give proof within such time, provided such proof is furnished as soon as reasonably possible. Time of Payment of Claim: Indemnities payable under this Policy for any loss will be paid immediately upon receipt of. due written proof of such loss. Payment of Claims: All i.ndemnities payable under this Policy will be payable to the Insured Person and nny accrued indemn.ities unpaid at the Insured Person's death will be payable to the estate of the Insured Person. Assignment: No assignment of interest under this Policy shall be binding upon the Company unless and until the original or duplicate thereof is received at the Home Office of the Company, which does not assume any responsibility for the validity thereof. Physical Examinations and Autopsy: The Company at its own expense shall have the right and opportunity to examine the person of the Insured Person when and so often as it may reasonably require, during the pendency of a claim hereunder and to make an autopsy in case of death where it is not forbidden by law. Legal Actions: No action at law or in equity shall be brought to recover on this Policy �rior to the expiration of 60 days after written proof of loss has been furn�shed in accordance with the requirements of this Policy. No such action shall be brought after the expiration of 3 years after the time written proof of loss is required to be furnished. Certi.ficates for Insured Persons: The Company will issue to the Policyholder for delivery to each Insured Person, an individual certi.ficate setting forth a statement as to the insurance �rotection to which the Insured Person is entitled and to whom indemnities provided by this Policy are payable. Clerical Error: Clerical error upon the part of the Policyholder shall not prejudice the insurance of any Insured Person nor shal.l such error continue the insurance of any Insured Person beyond the date it �vould otherwise terminate under the terms of this Policy except for such error. - 7 - , , , _ Conformiky with State Statutes: Any provision of this Policy which, on its effective date� is in conflict with the statutes of the state in which this Policy was delivered or issued for delivery is hereby amended to conform to the minimum requirements of such statutes. Not in Lieu of Workmen' s Compensation: This Pol.icy is not in lieu of, and does not affect any requirement for cover.age by, Workmen's Compensation Insurance. PROVISIONS REQIJIRGD BY T AW TO BF. STATI:n IN THIS POT_ICY: - "This Policy issued under and in pursuance of the ]_aws of the State of Minnesota, relating to Guaranty Surplus and Special Reserve Funds." Chapter 437, General Laws of 1909. IN WITNESS WHER�OF, the ST. PAUL FIRE AND MARiNF. INSURt1NCE COMPANY has caused this Policy to be sigried by its President and Secretary, but the same shall not be binding upon the Company unless countersigned by a licensed resident agent of the Company. /,/ � ' 1:.,�,tJiJC— �, IJ�X/�� . / � .• - 'C�iL��C�YY� Secretary President Countersigned by Licensed Resident Agent - 8 - t ' PREMIUM SCHEDULE The monthly premium due the Company on the lst day of each month for the insurance provided in the Policy to which this Premium Schedule is attached shall be calculated at the rates set forth below: Employee Only $ 2.00 Gmployee and Dependents $ 5.25 Form No. 12320 PSR Ed. 11-69 . � . • . I .� f �� . • °i . . j .i i � � - : . . . � \ ... � • SPECIF�,CATIONS i ' ' This Contract is for the term af one yea�r� beginning � . , at midnight Centraj Standard Time on the last day of Febrvary, ,� � : 1958. Unlc•ss discontinued by the City, it shall be renewed - �� : .. a u t oma ti.cal l y on the f irst• da y of March, 1959, and each suc- . � ' �� " � cess�ive year thereafter during its continuance, for successive �� ' terms of one year each, without medical examination. Any re- , ..�:;� � � . quested cost ad,justments shall be made in writing to the City � !°' � � � . prior to July lst to be considered for the next fo�lowing ; , : �� yearly term. This Contract may be canceled by the City by � ' ` a �` � , written notice gfven on or before February lst. , ° ,. ,.. ; �.•: . ' All accounting details will be handled on a short � � : , ; form or self accounting basis. Any employee becoming eligible ; ,' ;; ;� ;� ,° �' f or coverage or terminating on or before the 15th day of any i .•, � ", ' � � �: ' month shall be accounted for on .the basis of paying for the ; full month. Any employee becoming eligible for coverage or ' ' ' terminating after the 15th day of any nionth shall be covered ± " immediately without charge to him or the City for the balance • j � ,. . of that month. Thereaf t er, the charges f or such emplvyee shall -� � • be as hereinafter provided. ! In the Event of conf lict between the provisions of _ i ' � any policy submitted as a p; �t of a bid herein and these speci- ' ' � fications, the provisions of� these three shall govern: , . . , ' � �• � 1, Request for bids � � '� �� 2. Specif ications '� i ' : 3. Insurance specifications (Exhibit A) . � . . . •, � Pre-existing illnesses and conditions shall be covered � � � by this Contract. : � � � l�etiring employees, terminated employees� and employees , �` � � ` on written leave of absence f rom employment in excess of thirty � (30) days , other than sick leave with pay, shall be c�iven the � right to convert with continuous coverage without evidence of good health to an individual policy or policies containing the ,' +' same benefits held under this program. Employees who have been ; suspended or whose employment has been interrupted temporarily ; by virtue of lay-off , lack of funds, etc. , for thirty days or , less shall be continued under coverage as if they were steadily , - employed. Leaves of absence or suspensions of over thirty days'. ' d�aation (except sick leave with pay or as o�therwise hereinafter � . provided) shall result in the discontinuance of the City' s contri- . � bution after the first thirty (30) days of such leave or suspen- • sion; provided, however, that City employees who are permanently � ' appointed full-time or part-time employees of the City and whose - : ` terms of employment in each year. are governed by the period of � ' � ' the normal school year (approximatel•y ten months a year) shall be , continued under coverage with premiums being paid by the City on ' � a twelve-month basis � the same as if such employees were employed � � by the City on a yearly basis. Employees, including elected and � � � appointed officials and their deputies, on leave of absence with ; � pay for sickness, shall be covered during such sick leave. Employ- �. � . � ees who are separated from service with the City for periods not ; � , exceeding ninety (90) days' . duration shall have the right to pay . I � • premiums under the , � I : •1• . . � . _ . • _ . ._ � . �; . . ' . . ,.� ' . �roup policy direct � and thereby continue unde.r li�e Nrdt�ttion � of the City group plan. Any employee separated from service � with the City for longer than ninety days ' duration shaZt be considered a terminated employee and shali thereafter be • � errt itled to the conversion rights hereinbefore provided : with reference to retiring employees , terminated emplo yees , : ' �and employees on written leave of absence other tha� sick leave with pay. . . Said individual policy in the case of life insurance shall be charged for at the rate for the then attained age set forth in the standard schedules of the company and without � penalty. Said individual policy in the case of hospitalization . and surgical and medi�,._ �insurance shall be charged for at the � . � , rate then being charged for individ�tal policies by the company - � without penalty. � _ Dependents ' benefits shall be allowed from birth to . �ge nineteen (19) if not a student � to age twenty-three (23) if _ a student or to the date of marriage� whichever is earliest. . The dependents of and employees in the service of the � _ City on the effective date of this Contract shall be eligible � , for maternity cove�age immediately upon commencement of the , , - program if the emplovee elects to pav f or de,pendencv coveraqe. ' : The group lif e insurance contract shall �ovide a , , waiver of premium benefit if an employee is disabled prior to � age sixty-f ive �(65 ). The accidental death and dismemberment coverage shall � include both occupational and non-occupational accidents . ,� There shall be no restrictions as to age for any � �f the coverages. , . ;, Specimen copies of all bidding companies ' pertinent j policies shall be furnished� but if there is a contradiction ' I between them and these three requirement sheets ( (1 ) Request ; � for Bids ; (2) Specifications ; and (3) Insurance Specifications ) i '. � the City's requirement sheets shall prevail. All officers and employees of the City of Saint � Pa�l employed by the City upon the effective date of the _ coverage herein contemplated shall be entitled to such • � � � coverage and payment of premiums by the City� subject to � the folbwing stated exceptions : , � ' 1. Persons employed less than six complete con= � � � . � � � ; secutive calendar months shall not tie covered � : '� � � ' until they have completed said six complete consecutive calendar� months. � „ , � ` � . � . . � . , - : � . .2. . � . . • . , . � � . � . � , , , � • .� . t • ; ; � _ � . � 2. All officers and employeea of the City who � •� devote less than half time to City business, - . � . .� � such determination to be made by' the City. � � . It is the intention of the City to provide paid coverage { for all officers or employeeS, including part-time officers �` ' or employees who devote at least half of their workin hours �" " to City business. Employees who devote less than hal� o ` � . , their working hours (a work wesk �a consist of forty �40� y � � = hours) to Cit business are not e igible �or cover2�ge exCept ' �' as provided a Page 1 of these sp�cificat�ons. � , � � : i . � � � . Every employee and ever appointed or elected o�ficiai i � . or deputy o such officia� must h ve comp leted at least s�x 4 � ' months ' emp�oyment w�th the City ef ore being eligible f or City contributions. However, . such per'sons may apply immediately and �- � ? �� pay the entire cost themselves on the same basis as eligible ' ` � , employees. Elective and appointed o£ficials hol�ing office �for�'• .' � ; successive terms� having once been covered, wil�; continue to be � , • � • eli ible for coverage for succeeding terms of o c�ce. All � i . o f f c e r s a n d em p l o e es e li gible #or co vera ge shQll have thirty � ; . - (30 days a£te in�tial 9mplqymen� by t e C�.ty in w�ich to app ly ; . , , for coverage w�thout evidence, of insura�ilit and shall have an j ; additional �hirty days a ter having been emp�oyed by the City � � , for a six-month period. �urin whic per�od they shdll be given _ � � ' ? coverage wit.hout -evidenc� of nsu�a�ilit}�. Coverage shall be � � � � extend d to de endents w�thou ev�dence df insurability where i � , de�ire� �bv emp�oyee� aft9r the employee has been employed by che 1 � . CsCy of 5t. Pau� for eix mon�he. ; . I .j , . , � ; � . � ,. , . , . The Ci�ty shal f urnigh successfu� bidder(s) with a . � list s howin :names of al� persorts ori inall y cov�red� and from 9 '�` ..� �� time to time ther�after vrith all addi ions and removals.�,therefrom. � � • '' . _ ; 1 . , , � , • , . . � . _ , i _ � . •, . , , � . . , , � � , . f , . . , , . . . ; , . , . . � � �3. � � � , . , � ; . , , , , . � , . , :� _ { • !, � • • • � . i ,, r # + . � , , ,' � ' , i., { . . .. , . , . •:,. , EXHI$IT ��q�� .. � . ' `i t ��; �NSUR.'�NCE SpECIFICAT IOrS AND PROPOSAL FORM I �. . � LIFE INSURAUCE � � � ' gmoun_,t f,^eid � � , , ;� Emplovee � . � � . _._ _ . - , , ;'_ �,:;; ,�f��GROUP LIFE INSURANCE - - - - - Benefit �1000.00 $� . �:.` r'. .�� " . 1'. . � .�'. j. : . � ACCIDFN["AL DFATH 8 DISMEMBERNiENT COVERAGE � _ - - BENEFIT--$1000.00 principal sum $_______ i. � � � * �c- � -� � � � � � � � i � � , . ; � HOSPITALIZATION INSURANC� � . . - Empl_ov_ Dependents� � ROOt�( AND BOARD - Full and complete payment of ; � semi-private room accommodations (2 or more � , ' ' beds ) � average semi-private -room allowance " . toward private roam accommodations within � � . each individual hospital. For 365 days per r; � . disability or conf inement - - • - - - - - - $_ $� � - . SPECIAL S ERVICES - To be paid in f ul l and shall • . ' � include : � , - . $_._ $� , 1. Anesthetics administered by salaried � . . ' � . employees � of hospitals � { 2. Operating Room ' - r. 3. Clin�ical laboratory service � i 4. Pathological laboratory service � - �, i � 5. . Surgical dressings , plaster casts r . � 6. Drugs , biologicals-.and solutions, listed � '� , in the United States � Pharmacapoeia, ?he . ' � , National Formulary, or New and Non-Official. ' `�'� . Remed�iesP except blood and blood plasma ' . ' 7. Serurns - � _ � 8. Intravenous solutions ' �� ' 9. Liver Extracts � - ' 10. Glandular Products � � ' 11 . Phys�.cal Therapy� i.ncluding diathermy� � � r�cliant I�Q�t > ultraviolot r�y , � 12. Oxygen Therapy - including gases � inhalatsons � 13. Electrocardiograms , � , 4 14. Basal I�Aetabolism Studies , . � ,. � � 15. Unlimited Diagnostic x-rays . � � . . . . . `'. .. V 1 • . � 1 � . . . . ! �� l+AAA?ERNITY BENEFITS - Maximum allowed under�; ' $� ' � • these specif ications .� � � . � :; . , , , . . � . ` ' . � -4• � . ' � ' , ! � � � . . . . � . ; . � . , . f • , . , , . _ � . .- �; 't • � . . � t. , E IBIT "A'' (COr1t'd) . ' , �, Am4u�t of Bi,d, � m lo e e Qe�:�n�` . ; OUt-PATYEM COVERAGE FOR ACCIDENTS - Eull � cost �.f treated in outpatient section of a hospital - includes diagnostic � x-ray, laboratory tests and other � emergency care . ' $=-- $"_"_" , Total bid f or Hospitalization Insurance �_ ------ � � � * � � � � � � * � � � � * * . - � SUaGICAL - MEDICAL INSURANC� ' S URGICAL SCHEDUL E - �200.00 ma x i mu m f.o r � . � : any one procedure - (Submit table of coverages ) ��_ �-.----- IN HOSPITAL MEDICAL CARE - 120 da ys maximum _ (List amou,nt of benef its per day � and all other In Hospital benefits)_,_„___„ ._._..__._. � � Must include benefits toward pro-. fessional anesthesiologist not a salaried �employee of hospital.� � , OITf OF HOSPITAL BENEFITS '(List Benef its ) ; ,�.,_...._ $--.-.-- �� Must include emergency care � � in hospital� doctor's office � � or clinic. ' ` * Amounts in Dependents ' Column shall be paid by employee. � � ** This cove'rage may be purchas ed by employee f or herself , if 8..1 , -. woman, o� uhder dependents ' coverage if coverabe�ranted to t�laternity benef its are not p8rt �of the 9 9 , ` . � an employee or dependents unless the premium for� �overage � ' is paid by the employee. . , ; � f�roposal submitted by ; ame o ompany S gna ure t e . . � . � . � . . . . � : . . ,� r . . . . . . . � . - ��... ..;. . � � ..� • .. ..� � � . . . � , . . . -�� ,. . ', • . .� . . .. . , . �� . � • � . ,. � . ., .. �. ' � • ; � , '._' i � . . ' ' ' ` _ . � , �� `� . �� 1 , . , , , I . . . . .. . ' _ ' . t ` . . ' +' . ', `, � :.i' . � , � � ` . , . . �i .�. . . , . ' . . �. .. .. . . . . . . . . . . , �. . . •. . . . . � . . � . . . , , ,:,. . • y� � . . - . . . �. . . . ' � . -.. . . . � . . . .��`� . . ' � .. . . . .Y � , . . � . � • .. . . • . , . . � . ..r- . .. . _ � . . .. � . . .. . . . . . .. . _ .. . . . . . . . . ... . I � ' :� . � : EXHIBIT "B'� � CITY El�LO�YEES , , (r�'� iacluding Fira, Police, or �acharo) � . f ' . A�e malea � emalea (Ige � males female i . U 0 1 51 29 11 � 1 - . 18 . 8 9 " 52 2� 19 ' i ' 19 a � lr - s3 24 15 . .; . 20 G 13 54 2y . � 9 . . � 21 . 17 � . 55 28 � , � ' 22 _ . 24 . . 11 , 56 45 , 1� ' � ' 23 22 � 19 57 42 16 � 24 34 13 � ' . 58 25 12 `� � 25 22 , 11 • ' S9 35 13 � 26 •� 26 10 60 �. 3$ .. 7 ' ? ' 27 � 33 1 _ 61 40 .11 �' 28 . 23 6 62 3I � 15 � ; : ' 29 � � . . 11 , 63 � 36 7 . � : �' 30 29 9 � . 64 , 25. 4 � � . 31 49 � 8 65 21 1 32 36 9 �� ' 66 ; 15 2 � • 33 36 . 8 . ,., 67 ' . , 29 , 5 34 ' 33 1 - 68 17 � 4 , • . 9 2 , 6 • 35 46 14 9 . , . . , 36 '. 42 ` 11 r: � , 70, ,, 16 3 : 37 . 37 • _ 10 71 . 5 2 � - ;, : 38 . 35 ; 17 . ' 72 � '' , , $ , : 2 _ , � . . . ., , 39 , 41 � ' . I2 ,: 73 - �' . ' 11 _ 1 . 40 3 7 ' , 15 74 4 0 41 37 � 17 75 � 2 6 . • ; 42 • ': 4� - , 18 ' � 16 �; � 3 �'0 � • . 43 � 36 �. 21 77 . 2 I � 38 . L . , 19 � . 78 � o 45 32.� 25 . 79 �' . . X , p� � 46 24 14 80 1 1 � � 47 30 17 81 - / 0 , 48 ' 28 10 82 d , ;. ,, o 49 38 8 � 83 1 . • 0 ; SO 22 L4 (Totala� ' 15�i8 � 638 I?@DendenCY St8tu9 � . �• emale • Single with no dependents - 278 , , ' : � • Sing�.e with 1 dependent p 12 � ' Single with 2 or more - 14 _ � , . , Married with no dependenta - II8 � ' _ Married with 1 dependent • 115 , , _ � • Married with 2 or more - 131 � a e +�� Single with no dependeate - 257 . Single with 1 dependent � 7 , . � • Single With 2 or �ore - 9 . , Married with no dependents - S. . • � . . : Married with 1 dependent • 4a6 . � , � : ' � ltarried with 2 or more • 8Z2 ` • ;: 1 . ' , . , ; \ . 6- . . : . . .. • ._ _ . : � r' : : .; , , EX}iIgIT "Bu ��011t1AUed) , :+� � . , . 7'F�A'G�,�S ' , �e ma lea fema lea ► e ma les ►�feckll� . 21 3 45 • 12 21 ' 22� 1 21 46 l�0 �9 � 23 3 23 47 ' 1� Z£1 . � ' 24 6 37 . 4t3 a 24 . : 25 7 34 49 8 ' 26 � . � 2G 7 22 SO 6 29 . , _ 27 15 . 23 ' S1 � 2 .., . 31 2a 18 26 52 10 31 , � 29 . . 20 ' 16 . 53 5 39 � , . 30 16 • 5 54 , ig 53 . 31 � 25 � 11 .' S5 . 6 , 34 : _ - . 32 24 6 ` S6 9 ^ 25 " 33 28 7 . 57 , • 5 30 � : ' 34 19 ' g 5� , 4 _ � 4� 35 26 9 59 4 , . ; 21 ` ` ' 3G , '' la ' , 9 60 � 3 31 , ` � i ' ' 37 21 13 1 - 61 4 24 � , _ . 3t3 10 11 62 4 26 ' '` ' � 39 12 14 _� 63 1 25 ;'' � ; . 40 , 5 . 10 ; � 64 3 � . 21 41 14 16 '.; 65 2 15 + - 42 12 , 21 • 66 4 . �4 � 43 ]k 14 � 67 2 15 � 44 ' 14 13 n. 6II �� _� � , . , . , . (Tot'sls) 476 �� . 1005 . , : • e ! . ' DependencY Status . . " ' Female •, Single with no dependent$ ;�- 590 - ' . Single with 1 dependent • 13 - � . i Single with 2 ar more - 7 ' ' � � , . � - : Married with no depend�ata - 13t3 � - .,I � Married with 1 de.peadent - 177 � � ' � , Married with 2 or more - 8n , - . � Male � Single with no dependents - 30 1 .•. . Single with 1 dependent - 1 ' ' � i Single with 2 dr more - 0 . ' , _ � ' M.zrried with no dependenta - ; 1 � I Married with 1 do}�erident '• 112 ' � Marrisd aith 2 or more - 332 '� � . . . � .. ,� . � . .. � . . ' . , . . . . . . .. ' �' . . . . . . ' � . . '�� . . . . � . . � . � '. . � �, . . . ' � � .. . . : � . .t �, � ' - . ' . .'� . . 4 . . ! . . � . . . . .. . � � � ' . . � . . � 1 . � . • . . . . . . ..� � .� . . , . . , .. . ' , ��.: .. � � � . . . . � ' .. . ' . ' ' . . J � . , . ' . - . . ,. . . . . . . ' ... .. . . . -�� 1 . . . . . . . .. . - (.� .. . . . ' .. . .. • . . � � , . , . . . 1. � � . � � ' .. " • . • . • . • . � . � \�- � � .. � . . .. . - . . . . � . ,. . . . � ' .� . . ' . . ' 1.1.:. . . . ./ . .. ' . . . ', .. � . . . . _ . .. ... .. . '�\ . . . . � . . ' . � ' . . . . . ' � iY .. . I . � , . . . . � .. : • � . �� • � �y��T.:B�� (Contiaued) . , � Pdi.IC AND FIRB . p�e males ' females � males fcmales _ . 18 0 2 43 28 . 1 . . ' 19 � p ' �s4 20 � � 20 p p 45 15 � ' . . 21 0 1 4� 22 � • . 22 � 1 1 47 IS 0 � ' 23 6 � 1 � � 48 18 � . - 24 8 1 49 16 1 ' , . 25 . 11 � p � 50 12 1 26 19 1 � . 51 � 10 0 . . 27 16 0 ' S2 ' 14 i • ' 28 20 0 � 53 16 � • . 29 . � 37 0 54 4 1 � .: , . 30 54 1 � SS 9 . � ' � ' 31 43 , 0 � SG 8 � � � � 32 44 0 . / 57 13 . : � � . 33 ' 35 1 / . 5I3 10 0 . , ; • . ; .�� - S9 ' g p ; . . ,� . 34 29 � � 0 . 35 37 1 . � . � GO ' 17 •; Ii � Gl 12 p. , i � ' � 3G ' ' 29 : 1 0 I , 37 I6 , 1 62 11 . � � � .. ' , , 3$ ' . 26 � � � ' G4 , 10 � �, I 39 27 0 � , , . - � � 40 28 0 . : GS 0 O ,- . i ,; ,. , 41 27 . • . 0 � E7 e. Z , 0 � ;' ' .42 35 ' i � . 1 . 4 . ,,,, , . . 68 ,,_, ,____ , ; � . • . - ° (Totsl�)' 849, 19 . � , . , . .' �,, , << Dependen� Status " � ., ti ••;; d. �,, ''`� � . � � F�e � Single with na dependenta - 16 " � y:, }. . � ° Single wiCh 1 dependent • 1 ; Single `rith 2 or more • 0 ,� ` � � , . , , Married with ao de�eadents • 2 . i � ,.� tSarried �ith 1 d.epettdeat - 0 . 1 � Married with 2 or more - 0 . , , . .i � ., � � � � M81� Single saith ao dependents - 45 ; . } . � Single irLth 1 dependent ' 6 . . Single vith 2 or more - 9 � ' . � Married with no depeadents • 0 � � Ma'sried with 1 'dependent -177 • � ;� � Hs�crisd vieh Z or oor� � �612 : . ;. , . i � , . � , , , . ; � � ' �. ,. ; � � � . . _ j . . � _ , . � � : ` � : i _ + - . � � " � r--:� , � . � . � � -- . � ';Po�e_.�3�oE•�'3"' �.�I.I�3IT �� . ___._.._._ � : To: City of Saint p8ul, Minnesota • (Life I�surance) , � . -- . Groas Paid Incurred Dividend or , . Year Pr_ Cl�ims Claim Charge Rate Credit • . . . 1 $SU,UUU.UO , , . ` ' 2 SU,OOU.OU 3 SU,UUU.OU , 4 . Sn,U0U.0U . 5 SU,U00.00 � : 5 Yr. Avg. SO,UUU.UO . � - .. - _ � � 6 . SU,UUU.00 7 SU,ODU.UO � SU,UU0.00 . , ; 9 ' SU,ODU.UU � . � lU , SU,UOU.00; � , lU Yr. Avg. SU,UOO.UO' � - - • ' . � Gross ' Paid �r Incurred Dividend or � � • :. ear Pr` Claims . Claim Char�e Rate Credit - � 1 . $35,ODU.OU ' . � 2 35,UUU.UU " 3 35,OOU.00 4 35,UUU.UO - � ' ' . , 5 35,ODU.UO . . � ; S Yr. Avg. � � 35,OOU.UO � . , 6 35,UUU.UO � 7 35,UOU.OU . , , . � 35,OU0.00 , ' i . . 9 35,UOU.00 lU 35,UOU.00 ,' ` - ; . lU Yr. Avg. 35,W0.00 • • � � _ - - - ............ . . _ ..... ..:..... ... _ ..�.....�__._ , , .. � � . , . . , , ,. , ; _ , . - . . . , . " ' : • � . 1' r'!�'�_._�..... _:.•.. .... . .� ... ....� .._:. ' . , . . "":" . . � . � . � � . . , .. � . .. . . . . . . �, . . .. . . .. .. ., J . . � ' . ,,. ,� . � . . � . . � � . ' - � � . . . . - . . . . . . . ' . . . � . � •' ;`. .y. . . . , ' � � � i ' �,�' . i ' � � . . . ADDBI�ID�1 �1 TO NBALTN AI�ID 1�1FARB SPBCIPICATIOi�S , • . . , . • , . , � • � , , � „ } `' 'a � ,,. , _;; .....� �; , .. . , � � ' Under Requeat for Bids, tbat paragraph steting the ,, y : , • psoposal ohould include: �. i. � , � . ; � � "Sinca these apecificstiona provide that retiring . • • • employees, terminated employees and employees on leave � of abaence in excess of thirty (30) d�ys are given the . ' . , right to convert their Covere�ge under the proposed ' . �; � . City inaurance program without evidence of good healt6 . ; , . , � � . . to an individual policy or policies coataining the . � ' � smne benefita held ut►der this program, bidders sball � + , ' submit schedules showing preeeot conversion ratce�in ' ' � � , : . ; . .. - effect at the time of submiesion of bida herein. Where _ � . � , � "^ � . the type of covermge percnits of dependency benefita, bidders shall ,. . . , submit achedules ahowing the change ir raCes, if any� relating •� � ' to such depeadency coverags �aa comrer�ion fraa Clty plan, : � if �y�" f,- , �, _ . ; : � . . � ' �. , - , ' : , , , , � . i �.. , i . , , ; . . . : _ , , i . . . I ' .. ' , . , . � • , . , � . , , : • , • ' , � , . . , � • , , . • . • �� • • � „ , , . �" ; , . . , ' . •. , ; � , '. � �� • . . , ' �. .. , . , . . � � . � � - '1- . ` � � . i . . . � � � . . � � � : � ' � . . .� ., . ;. � ' �� . . � . .. . `'�.� � . , . -. . r . . . . . . _ �` . . . �_ � . .. � - . . . � . � � . � . v %� . . , �, A a R H S M t N T TN� AGRBB�taNt� Mad• and �nt�r�d into thi• 28th . day oi l��bruary. 1958• by and b�tw��n th• 8t. Paul !ir• and � M�ri�� In�uranc• Coo�pany� a Minn��ot� Corpor�tion� Party ot • � th• l�is�t part, h�r�in�it�r d�ai9nat�d a• "Inaur�rM, �nd ' tf►� City oi �iai�t Paul� a �unicipal aorporation, Party o� tA�;i�QOnd P�st, h�r�ina�t�r d�si9nat�d as tA• •City", ° MITNd��Ttit� � Th�t i� .��d tos th• oonsid�ration h�r�inatt�r A�n- � tion�d. th• inaur��c h�r�by a9r��• to turni�th th� Cily with aov�ra�� o! its, a�ploys�s i� •ts4iat aceordanc� with th� arard � ot aontr�et and th• �p�citia�tions tA�r�ior, and in accordana• rrith th• bid os propo�al oi th� IM1��r �ubaiitt�d purswnt , to adv�rti��nt th�r�los ��oswt Bid N�. 6691). Nhich sp�ci- - tieationa, �rard oi aontsact. bid or propo�al and advsrLisN � Nnt th�r�tor �s• wrd��a p�st h�r�oi by r�i�r�na• as tully •� and 6o�l�t�lr �• ii s�t torth A�s�in in th�ir �ntir�ty. � " . _ . It i• iurth�r �utu�lly aqr��d tMt it lh�r• b� �ny .. . inconsist�nay os conts�diatio� bitMn�n !A� �p�cia�n polici�s ; ,�: ,= �, , �•.tusni�hM by th• I�ur�r •nd th• sp�citic�tion�, awsrd of � � aontr�ct, or adv�sti�a�nt �os bids, suah sptciticationa, � �rr�rd ot corttr�et �nd �dr��rtis�pnt tor bidt ah�ll eontrol. '� • Tt i� furth�r wtually a�s��d t?�at, in addition to tA• t�r�a and conditions oi •uah �p�citications, adv�rtis�nt �or bids• tl�� propoaal oi th� t�aur�r and th• aMard oi th• � aontra�t, th� lollowin9 alaus�s ar� �sd• • part o! tA� � ; A�r��t bitw�n th• p�sti�a� . � , . � � {� � '3 .�..�.�.••,,;«;.,,..,,,�:. ��:� __ � __ . _ . _ __ . , ' � • ', ; . I _ . i . 1• �i� �9r@��nt can b• t�rminat�d only a� pro. ; vid�d in t?�• •p�ciiicationsj • � � '; Z• Th� insur�nc� covar� � 9 provid�d ior h�r�by can , . b• Qonv�rt�d onl as , Y provid�d in th� sp�ciiiwtionas �. , ali�ibilitr ot �aploy��s ior cov�ra9• on and � •it�r !h• ��t�ctiv dat• o� � lhis A9r��ra�nt, th• lat day of , Mar�h,�19�8� sh�ll b� •stabli�h�d by a�solution of th� Council• . �i Counoil �il�� No. 186�l7� adopt�d l��bruary Z8� 1�8, a�d th� �p�aitieationsi 4. ?A• City aqr��• to pay th� insur�r. as con• •id�ration tos th• �ull �nd t�ithiul p�rtos�snci oi thi• ,Aqr��nt• in acaordanc� M►ith th• sah�dul�s of pr�aiwas s�t out in Insur�r�s proposal. � 0. Oplional �o�thly incaa� coverage (acaid�nt and , �iekn�sa in:�s anc�) and optional ��or n�dical and sur�ical . cavisa�• noM inaurin9 City oitiaial• and ��ploy��• will con• , �� ti�u� in •tl�ct on th�ir pr�i�nt baais� ar�d •uah aov�ra�• . will b• oii�s�d to •11 •li�ibl• City oiticials �r�d �ploy��• �t th�ir own �xp�na• by th• tnsur�rf � , � d. Th• City a9r��s to par Pr�u�iu.s tos �Aploy��s _ �1i9ibl• ior City�p�r cov�ra9� h�r�und�r dur�rq th• t�ra oi thi• Aqr��t�t or any �xt�n�lon th�r�of� how�v�s. �aploy��s . Mho •�parat• !ro• os l�s�inat• th�is �aiploy��t with !h• CitY , ! �hall no! th�r�att�r b� aonsid�r�d �119ib1• a�ploy��s !or th• purpos• o� Cilr'PaY aov�r�p�. and Cilr� PaY��nt tor suah �a�� pioy��s �h�ll not aontinu� b�yond th• cal�ndar eonth durin9 "' ' �ah �n •uah � y �wploy�� t�s�inat�� or •w�rs hia �ployn�nt . . _ �rit1� th� Citr. Yh� Ya�we�s th�s��lt�e a��• to �11oMr tA• , . ; � . ; •�� .� � � . . t� �". � . . . •s�pior�• thirtyon• ��l� days in which !o canv�rt, City•�,�� " oov�sa9• to �n individu�l poliar providin9 tA� •sa�� c�v��:��r� � •ueh lndiv�dual pal�cr sh�ll b� �ti�otiv� on th� tisrt d�ts � th� �wploy�� wa• •lipibi• to aamr�a� to •ucA cov�r�g*1 �. , ��. , 7. Th• b�n�iit• und�r thi� A�ac�rs��ns •r• psyabi• ,� , te th• a�ioy�• in a��,r +�t hi� �ption in a�ditson to any �nd r ,�, •11 b�Mlit� h• �y b� u�titl�d �o undos any individwl os ;.,: .ta�ilY insusana� polieY, but not wwl�r aa�l otb�s qroup ir� n� ��: •us�n�• i��u�d br th� Inaur�s� „' �,. �, •. �lo�• eov�r�d u�dd�t th• ps��nt e�ployt� , pa�r•all �roup in�urana� psovid�d br th� 2nsur�r �nd �ho art 4 y - not �li�ibl� �or ao��s�9• provid�d und�r thia A�r��nt obili . b� �llo� ts P�r Ptt�i�ap dis�ot tos th� �oqths oi lrlasch. � , � Apru atw wy 195�� , � � � 9. �xp�si�na• satinq s�lunds ��sn�d h�r�und�s on _, . Cit�Y aov�sa9r �h�ll b� �ad� to th� Ci�r in aa�h1 � � s 10. No proyi�ion o! this Aqr�M�nt os th� cov�r�q� , .. � ps�onidrd tos A�s�uad�s ahali vat in��ny Mploy�� siqhta �hieh Mpuld orw�n! �odiila�tion-os ol�esp� ot this AQr��+ ' � �wnt or th• cov�ra9• th�sybr pzo�ridw br �utwl a�s�Nant � �`� ` �• ,� , ' •t tn. p.�s.. n.s.to� � � . 11. Any Mpleras aiitt�d �roo aov�r�q�, b�aaw• ot �i�tak�, inadv�rt�na• os al�riaal �rror on th� par! ot , �ith�r th• Citr or th� In�ur�s shill b� eov�s�d tro� th� ti� � . thnl �rould hav� b��n • li9ibl• tor aov�ra�• in abs�na• o! su�t� � wi�tak�, inadv�rt�na• os el�riaal �rrori anY �ploy��• i� : clud�d w�d�r Qov�sa9• D�Qin�• o! �istak�, inadv�rt�nc• or , � , al�rical �ssos oa th• past o! !h� Cily or th� I�sur�r ahall � �xslli��d �i'�0� �ti �1M t . ' ' 4;� 11� M�Y� bar� `NII �fNli�ufl� �'O= � � � , ,. . � , a �. � . . �� , , . , . ., r c�v��c�pe i� •D�#na• n! �u�h a�iot�k�, inadv'�rtsn�e or cloriasi `; •xror� �rw! no pr�ml,u� ah�la b• paid tor •ucA cov�rsg�. �nd ;;, f � ��Y Px��nt rrl�icA .rr�r• paid �or •uah aov�r��• •hall b• } # s�turntd� ' Y ' �tZ. Th� Ynsur�r sAall A�su• !o th� City • tormal �= , � wit!� 9ro�p poliay, a�ttinp torth th• t�ra�� o# th• in�uranc• , . t� b• p�rovid�d 1��r�und�r� � ;�� . � ; . l�. Th• Inwur�r •h.ii iwr,�.h o�stitia,at• ot iruurana� t� ��ah 1MY�td �10Y�� i��tlt�p �01"�h th� b�n�t�ts to which •uah �p�oy�� i• ��litl�d and �o �rho� suah b�n�tits �s• paYabl�s 14. 8ub1Kt to dir�at payav�nt o! pr�iniu�, cov�ra�� `:.� oi +aPlor��t on l�av� of �b��ncr or t�rnporary layotf �shall �.. , b• continu�d �or • p�riod o! �t�x raonths �lt�r di��oatinuanc• :� � ; N.� � � � � •� Cit�pay oor�sa�� !or �uah �aploy��s� ' � 1�• ta�ploy.• arawin9 Morlcw�n•a Co�n�►atson pay : , . ` � � Nnt• lro� !h� City. who ar•'o�b�s�ri�� liqibl• l�or aov�ra • - ; 9 �" ��. �� ' ��: �• �tY ��P aa��s'�9��' ahall r�auin �li�ibli i�r " � � �uah cov�sa�• duri�� th� p�riod o!� tia�� os which t��y r�c�iv� , . , ;�r1cNn�� Co�p�ns�tio� pay�nts lsoa th• City. 1'A• City will�. ,�: �ak� pa�nt� durinp •ua� p�riod�t und�r th� CitypaY Portion o� �h� 9s'o�P proqraw !or �aploy�ts �li�ibl� tor Cit • a ; � YPY „ ; . '� ,. sovfraq��' and th� �rploy�• �h�ll b� �ntitl�d �to �akr dir�ct � p�ri��t i�r Qov�ra�• to whi�h th� �ploy�� is �ntitlyd and ' . � � '�; �' fos �iiah t�� Citr is not akin� pay�nt��, Th� aioraa�ntion�d ��j � � , : i��ti •� �21�11 ,1'lOt ��iAd � . " �, ' f , � �yond th�. .t��r oi� this Aqr��mtnt. � � , � � , , ,, „ . • � ;� , IN �?Niia �itR�ol�, YU: Csty� �and th• tnsus•: hav . , a � r _ . � , .. .: , . � � � :� . , . ; . � � � . :, . � . . � , . . ,, i . . . � � � �t« � � . , � , ..r .,�. ..,.:,. . . . ; a , . � �ipn� tAi• A9r��nt !A• Oar •n�l Y�ar tir�t �bov writLtn. _ IN PRl[iBNCQ 0!t �T. PAVL fIRQ A�I b'!►ilAtNt TMSURANCB a3t�PANY h . : tts � � l�RM APpRtJNBD1 � . . ► , ' CiTY Ol� 8AINT PALQ. 1 • ` s. • • � �A rp0l� A YAt ' �� . � � Yos Oount�rti�n�d� , � , �y - � y �r . � L � ` At«�I��Y � � �� AIW �� • � thi� ,�,�� day o� �aiah;Y,_19�8�� °�� , �: . ' . . , .s: . �/G ' � °' • • 1'p0)l'i OA Y11�• .: : , , : . . \ . . . � � : . � � � _ ' r� , . , . � . . . . . � , . . ; , . ,.. , . � ; . ,. , , ,. �. ; _ . . a •' ' � �1� _. - ,r' . ; ,+ : . , . . . ' s i . , 5 � i . . . � .. . . . . .. . . . Ai , . . . . � � . • � . . . . . . � + �. . . � . . . . . � ... . . ' . � � �- .. .. . . . ,f ' . . . rT � , " �: . � , . . Y. .. • . �1! .. �+�.�J�' . _ ; � .�. . � � .. . � .... j . . . � , . . . C. . . •,.}�. , � ' � ' . . , � � ' . t, � . . . . . . . . .. � . � � . . . � � . . ' �. :.i . . . � . ..� . . . .'� , . . .,. . . � ... . . . . �� , �� . . .. . . � . . " ' , . . . . . � � �.. . . . .�. � . . . . . . . �� . ` • . . � . . . . . .. . . . � � � .. . .. � , ' . " � . � � � . , . � . � �`u�, I . , . � . � , .. � ' � ... ' ' . . � . .. . � . . . . . , � ,t' . . . ' . . . � . . .�� . � �� - .. • . ... .. . , ? . .._. . -.. : . � .: � . . . . . � . . .��. . ,. . . . � � ..:"��.. .. . ;.d� � . .. . � . . _ . _ . .. . . , . .. . . � . . .. . � .. � . . ... �� . . .. _..... . ._,...»�,.�.w. . Part. III ANESTHETIST �XPENSE The Company will pay indemnity in the amount of the expenses incurred for administering of anesthetic by an anesthetist (not a salaried employee of a hospital) to the Insured Person, or covered Dependent, when required in connection with a surgical or obstetrical procedure fo� which indemnity is payable under this Policy, not exceeding 20% of the Maximum Amount specified for the applicable surgical or obstetrical procedure performed as shown in the Schedule of Surgical or Obstetrical Procedures. Part IV IN-HOSPITAL MEDICAL EXPENSE t3ENEFIT � The Company will pay indemnity in the amount of the expenses incurred for visit(s) for treatment(s) made by a Doctor while the Insured Person or covered Dependent is confined as a registered hed patient in a Hospital because of such injuries or such sickness, except Pregnancy, not exceeding $3.00 for each day such visit(s) for treatment(s) are made during such confinement, but not more than 70 days on account of any one accident or sickness. Provided always that no indemnity shall be payable under this PartIV for expenses incurred on and after the day a surgical procedure is performed unless the amount payable for such visit(s) for treatment(s) by Doctor made on and after the day surgical procedure(s) is performed would exceed the amount payable for surgical procedure(s). ACCIDENT FIRST AID TREATMENT AT GLINIC OR DOCTOR'S OFFICE Part V OR AT HOSPITAL AS AN OUT-PATIENT The Company will pay indemnity in the amount of the expenses incurred except such expenses for which indemnity is otherwise payable under this Policy, for emergency first aid treat- ment received by the Insured Person, or covered Dependent, at a clinic, Doctor's office or at a Eiospital as an out-patient, because of such injuries, within 72 hours immediately following the occurrence of the accident, or at a clinic or poctor's office beginning within 10 days after receiving emergency first aid treatment at a Hospital as an out-patient, not exceeding in the aggregate $25.00 on account of any one accident. DEFINITIONS A. "Dependent" means only the Insured Person's spouse and unmarried children (including step-children, legally adopted children and foster children) under 19 years of age if not a student, or to age 23 if a student or to the date of marriage, whichever is earliest. The dependent child age limits shall not apply to a dependent child who is incapable of self-sustaining employment by reason of inental retardation or physical handicap and is chiefly dependent upon the Insured Person for support and maintenance and who becomes so incapable or dependent prior to attainment of the age limits stated herein, if the Company has received satisfactory proof of such conditions within 31 days of such dependents attaining said age limit. B. "Total Disability" with respect to the Insured Person or covered Dependent means complete incapacity, while under the care of a Doctor, resulting from accidental bodily injury or sickness which (1) wholly prevents the Insured Person or Dependent from carrying on the regular and customary activities of a person in good health and of the same age and sex, or (2) requires hospital confinement. C. "Pregnancy" shall include resulting childbirth or miscarriage or complications therefrom. D. "Doctor" means any person, other than the Insured Person or a member of his family, who is recognized by the law of the state in which treatment is received as qualified to treat the type of injuries or sickness for which claim is made. E. "Hospital" means only an institution operated pursuant to law for the care and treat- ment of injured or sick persons, which has organized facilities for diagnosis and surgery and 24-hour nursing service. In no event, however, shall such term include an institution which is principally a rest home, nursing home, convalescent home or home for the aged. - 3 - ..:Y�o��' �� a► r`t��a i��-��ca�t � . . ,ti �, , �= � ; ♦ .9Q!� � .r.. �1 �i�.: _.... :•j+ jl t�r�zs�?�'!.� i��i h.?1��4 "E ii�.y�°�''S'�I..�l(}7':.,.. �+f�„" .� 1� 19��'�� fl'��k.,�(�t .... ,�.ryC� V��C ...�- i .. . ?l:;��. � . �� ' ,�3 ' � . . *Y�.'`4' , �''F3.!}�. :!j.�`i t+QeF': f��ii(%tj�''��f �!.. -..��.i:lv. , ,.ii?;. �,^ +:'iJo'.:_�l'.� i`...1f�.. !1� 'J vt��. .. .71 :1..{i�. _. .t.. . . . ., .. ) ,Z!".�n.aSl . ��1:'. . . . . y pl r� :!f ,., .. 4.', :.fA�Mjt�71,�M1�M .�::A 4'��.�'�,"�ip . �M � 1��...�' ! � .. . � _ .. • ..1^^.' ,J�17. .f,� t.;t...� ��iflr��' �1 ��4.75�d'91�� YCr x ' : t �1`-'.'��t: 1�.7� ..: f3�"� �, .��`�2-��j - ki. ti. .,,+�,�:y pC: 'YO� `ff'-� �- "R! 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