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235217 J qR6GINAL TO CITY CLERK 235�.�M� � - � � CITY OF ST. PAUL FILENCIL NO. r� OFFICE OF THE CITY CLERK C U CIL RESO ION—GENERAL FORM ____ PRESENTED BY COMMISSIONE � DATE RFSOLVED, By the Council of the City of Saint Paial, that - pursuant to the provisions of reaolution of the Council, C. F. No. 230996, approved November 29, 1966, that the Mayor of the City of Saint Paul is hereby authorized, on behalf of t�he City of Saint Paul, to execute a policy amendment rider to the City's group iizsurance �� policy between said City and the St. Paul FYre and Marine Insurance \ Company perta3ning to Policy Number CEO-920, a copy of said amendment rider and policy modification being attached hereto and incorporated herein by reference, ae fully and as completely as if set forth herei.n verbatim. � FORM APPROVED / Asst. Corporation Counsel j . � COUNCILMEN � �EP z 9196�1 Adopted by the Council 19— Yeas Nays Carlson Dalglish ��P 2 9 �9�� proved 19_ Holland Meredith �n Favor _ / � . Petereon � Mayor Tedesco Against . ��`� Mr. President, Byrne OCT � pUBL1SHFD ��2 - � �,: . , �� ,�.�- . , ,�,�� POLICY CEO 920 AMENDI�NT RIDER '� Attached to and forming Policyholder part of Policy No. Cit of St. Paul Effective Date CEO 920 December l, 1966 In consideration of the payment of the monthly premiums as provided herein, it is hereby understood and agreed that the above mentioned Policy is extended for certain eligible persons as described herein as respects the following benefits, described in full in the above mentioried Policy, as follows: I (a) SECTION A, PART I - FOR SURGICAL PROCEDURE EXCEPT ON ACCOUNT OF PREGNANCY. • (b) SECTION B, PART I - FOR OBSTETRICAL PROGEDURE PERFORMED UPON EMPLOYEE OR DEPEN- DENT WIFE. � (c) SECTION B, PART II - FOR ADMINISTERING OF ANESTHETIC BY A PROFESSIONAL ANESTHESI- OLOGIST. (d) SECTION B, PART III - IN-HOSPITAL I�DTCAL EXPENSE BENEFIT, limited herein to an amount of $3.00 for each day visits for treatment are made, subject to a maximum of 70 days on account of any one accident or sickness. (e) SECTION B, PART IV - FOR MEDICAL EXPENSES INCURRED FOR ACCIDENT FIRST AID TREAT- MENT AT CLINIC OR DOCTOR'S OFFICE OR AT HOSPITAL AS AN OUT-PATIENT. II ' ' P The EXTENDED COVERAGE provision contained in the above mentioned Policy is applicable in its entirety as respects the benefits provided by this Rider.�'� . III The LIMITATIONS provision contained in the above mentioned Policy is null and void and the following substituted in place and stead thereof: LIMITATIONS Successive surgical procedures or successive visit(s) for treatment(s) by doctor while confined in hospital shall 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 three calendar months. Benefits as provided hereunder shall be payable for either such injuries or sickness or pregnancy, but for not mbre than one during any one period of time. IV The provision entitled EXCLUSIONS contained in the above mentioned Policy will be applicable in its entirety as respects the coverage provided by this Rider. �'�The EXTENDED COVERAGE provision shall not apply to the benefits provided by this Rider if termination of insurance is due to the employee or his dependent spouse reaching age 65. . �; : ` 's , ; ,' • � � V With respect to the coverage provided by this Rider the DEFINITIONS, ELIGIBILITY, EFFECTIVE DATE OF INDIVIDUAL INSURANCE, EFFECTIVE DATE OF INSURANCE WITH RESPECT TO DEPENDENTS, EVI- DENCE OF INSURABILITY, TERMINATION OF INDIVIDUAL INSURANCE, TERMINATION OF INSURANCE WITH� RESPECT TO DEPENDENTS, REINSTATEMENT OF INDIVIDUAL W SURANCE and PREMIUM CALCULATION pro- visions contained in the above mentioned Policy are null and void and the following provisions substituted in place and stead thereof: DEFINITIONS ' (1) "totally disabled" or"total disability" whenever used in this Rider, shall mean confinement in any hospital or inability to perform all the activities of a normal person of like age and sex. (2) "employee" whenever used in this Rider, shall mean any person eligible in accordance with the ELIGIBILITY provision of the Rider. (3) "dependent" shall mean only the employee's (a) spouse, and (b) unmarried children, (including stepchildren, 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; and (4) "pregnancy" shall include resulting childbirth or miscarriage or complications ' therefrom; and � (5) "doctor" shall mean any person who is recognized by the law of the state in which � treatment is received as qualified to treat the type of injury or sickness causing the loss for which claim is made; and � (6) "insurance month" shall mean the period, and each subsequent like period, beginning on the date_ of the month the group policy becomes effective and extending to the same date of the succeeding month, Standard Time, at the address of the Policyholder. 'ELIGIBILITY � Each employee who avails himself of early retirement from the City of St. Paul's Police or Fire Departments prior to reaching age 65, an or after May 1, 1965, will be eligible for insurance as provided in this Rider. Such employee may also insure with respect to his dependents. , . EFFECTIVE DATE OF INDIVIDUAL AND DEPENDINT INSURANCE The effective date of the insurance of an eligible employee who makes written application shall be the effective date of this Rider or the first day of the month following the date of this Rider or the first day of the month following the date of his retirement from em- ployment with the City of St. Paul. The effective date of an eligible employee's insurance hereunder with respect to his dependent(s) shall be the effective date of such employee's insurance hereunder or the date he applies for such insurance, whichever is later. • Where an eligible employee or any of his dependent(s) are totally disabled on the date their insurance would otherwise become effective, such insurance shall not become effective until the date the total disability has terminatedo i , . � .a ' 1 Jy . . .,,. . - .�s- -� N 4 -' ' � EVIDENCE OF INSURABILITY Each eligible employee who applies for insurance here�under with respect to himself or his dependent(s) more than 30 days after the eligibility date shall be required to furnish evidence of insurability with respect to himself or his dependent(s), as the case may be, satisfactory and without expense to the Company. TERMINATION OF INDIVIDUAL IN SURANCE The insurance of the employee shall terminate automatically at the end of the insurance month for which his pre mium was last paid and accepted by the Company in the event: (a) the group policy is lapsed or discontinued; or (b) the required premium payments cease to be made; or (c) the employee re aches age 65. • ' TERMINATION OF INSURANCE WITH RESPE Cf TO DEPENDENTS The insurance of the employee with respect to a 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) the group policy is lapsed or discontinued; or (b) the required premium payments cease to be made; or (c) the employee's insurance terminates, except in the event of the employee's demise; � or � (d) a dependent child marries, attains the age of 19 if not a student, or attains the age of 23 if a student, whichever is earliest; or . (e) a dependent spouse ceases to be married to the employee or is granted a legal separation. or reaches age 65. � PREMIUM CALCULATION The monthly premium rates for the insurance afforded hereunder shall be calculated at the following rates: $2.00 per month for each employee without dependent • $5.25 per month for each employee with dependent The Company reserves the right to establish on the anniversary date of the group insurance policy to which this Rider is attached, beginning January 1, 1967, and any , anniversary date thereafter, new premium rates at which subsequent premiums shall be computed; provided the Eompany gives notice to the Policyholder of such new premium ' • rates on or before July 1 prior to the anniversary date upon which such new premium rates will become effectiveo . ' :-� . .. �. • ✓ y .�'Q� ��p• : • VI The provision entitled NEW EMPLOYEES contained in the above mentioned Policy is null and void as respects the coverage provided by this Rider. VII The provisions entitled FR$E CHOICE OF HOSPITAL AND DOCTOR, WORKMEN'S COMPENSATION NOT AFFECTED, and EXPERIENCE RATING contained in the above -me,n,tioned Policy are applicable in their�entirety as respects the coverage provided by this Rider. VIII T'he provision entitled CONVERSION PRIVILEGE contained in the above mentioned PoLicy is null and void and the following substituted in place and stead thereof: CONVERSION When an employee or his dependeri,t spouse have been continuously insured under this Rider 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. IX The provisions entitled STANDARD PROVISIONS and ADDITIONAL PROVISIONS contained in the above mentioned Policy are applicable in their entirety as respects the coverage provided by this Rider. Accepted by C of Sai.nt Paul Pol ho er By . Nothing herein contai.ned shall be held to va�y°�lter, waive or e d any of the terms, conditions, provisions, agreements or limitations of the above mentioned Policy, other than as above stated. IN WITNESS WHEREOF, the ST. PAUL FIRE AND MARINE INSURANCE COMPANY has caused this Rider to be signed by its President and Secretary. . �--¢-e� ��.�°.��. Secretary President Countersigned sed Resident Agent Form No. FAP Ed. 11-66 �rLICATE TO PRINTER /4�I��F� �� - CITY OF ST. PAUL FOENCIL NO. OFFICE OF THE CITY CLERK ' COUNCIL RESOLUTION—GENERAL FORM � PRESENTED BY COMMISSIONER , DATE _ RE.SOLVID, By the Council of the C3ty o� Saint Paul, t�hat pursuant to the provisions of reeolution of the Couneil, C. F. No. 230996, approved November 29, 1966, tha.� the Mayor of the City of Saint Pau1 is hereby autharized, on behalf of t,he City of Saint Paul, to execute a pol3cy amendment ri.der to the City'a group ineurance poliay between said City and the St. Paul Fire and Marine Insuranae Compa�p pertaining ta Policy Nimlber CEO-g20, a copy of said amenc�ent rider and poliay modification bei.ng attached hereto and incorporated herein by reference, as fully and as ca�pletely ae if set forth herein verbatim. �� 91967 COUNCILMEN Adopted by the Council 19_ Yeas Nays Carlson ��P 2 9196�' Dalglish Approved 19_ Holland Meredith n Favor Peterson �Y�r Tedesco � A gainst Mr. President, Byrne �2z