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235218 �ORIGINAL}.TO GITY CLERK , c� ' CITY OF ST. PAUL couNCi�• ��'����� ' • OFFICE OF THE CITY CLERK FILE NO. _ � '� CIL RESO TI N—GENERAL FORM PRESENTED BY COMMISSIONE DATF — RESOLVED, That pursuant to the provisions of resolution of the Couneil, C. F. No. 229337, approved June 30, 1966, the Mayor of the City of Saint Paul is hereby authorized to ezecute, on behalf of sa3d City, an application and rider, a copy o� which are attached hereto and incorporated herein by reference, pertainin� to the City's group health policy pertainin�c to retired City employees, sa,i.d agreement � be3ng betReen said City and St. Paul Fire and Marine Insurance Company. � FORM APPROV D / ' Ass . Corporation Counsel .i COUNCILMEN ��p� ti 9196� Adopted by the Counci 9— Yeas Nays _ SEP Z 919G - Carlson ' Dalglish ' � pproved 19— Holland Meredith � Favor ' / ' Peterson � � yor Tedesco A gainst � Mr. President, Byrne Pl�BL1SHED a�T 7 ���? �22 y;. � f ,� i . , �, �... �f��'•�!• _^ • ` • � ` ' ,• • ,n. , �+�� � i� � • �� p,{, . • +_ . - ' '� �' . �.�C'�", > , ' • • �• � `� . .l� , . , . ' - � . ' • � ` t� ' • � . ��r' � � � ' . � � , . . � � . , , • : • . 2` ' , . , ' . , • _. . • ' • . i' • . ' . � ' ' °� • APPI.ICATION � � ' �� + � ,. • - ; . '� ; • , � . • • - • •; � • Application is hereby made by: ' ' G - �� , � - . . . . . . . I - ' CITY OF ST. PAUL _ , � ' � (Herein called the Policyholder) , • whose address is:- ST. PAUL, MINNESOTA - • , ` �� , - � to the ST.PAUL FIRE AND MARINE INSURANCE COMPANY, St.Paul,Minnesota 55i02 ' ' . for fhe insurance afforded by Policy Number CEO 921 • the terms of ' � , , which'are hereby approved and accepted by the Policyholder Yo take effect on the Effective � ' - ; Date specified in the policy. � . � � . ; � It is agreed that this application supersedes any previous specifications for thia insurance. � ` � . . � . � � • • � � ' .� �.� ' � . � . r, , , , , • . • . �� Dated at ST'. PA(lT.9 MTTQNF.S(1TA thie FT_ . T . ,� . , � , � • day of .Tf1i.v , 196&—_. • ' . , . . • . • . � , , , , , . . Policyholder �it of Saint Paul . , � � Signature and'I'id ' , . omas . ,� y , . ' � Witnessed by .. A�emY ' _' , , . . q .� � � . �— . . ,, ' •' , • � , , . . ! ,.. ' / . � �•. �'orm No. 13802 ABT Rev.7-63 ' • • ' � _ . � � � . ' • . , ' � . ' ` - , -----� �--�---�- --r , -,- —....-� - - - - -• � , --�-- ��.-.�_ -- -.-, —:- . - , . ;�� , • - , . � ' ` . • • '• • _' r� ' , . ,� . ;" ,� • . ' - •� '. , .�. . . . . •;,,.� . . • , . , , ' , . ' , ` . , . � . , — -_._���� ' . RIDER �`�� • Attached to and forming '"Effective Date �G�d Policyholder ' . � part of Policy No. ; CEO 921 .Jul 1 1966 CITY OF ST. PAUL . �"12:01 A. M. Standard Time where the Insured resides. ' . � i In consideration of the premium for which the above men�tioned Policy is issued, it is ' hereby unders�tood and agreed that no benefits will be paid under this Policy to an . , Insured Person or dependent spouse, if eligible and covered hereunder, Zo the extenz that such benefi�t payment duplicates any benefits payable to such persons under the Extended Coverage provisions of Non-Occupa�tional Group Accident and Sickness Policy No. CEO 920. , However, nothing herein �shall be eonstrued as reducing or intending to reduce benefit payments �to an Insured Person or covered dependent spouse �to which they are entitled under rthe provisions of Non-Occupa�tional Group Accident and Sickness Policy No. CEO 921. ACCEPTED BY ' Policyholder . . ' , . Nothing herein contained shall be held to vary, alter,waive or extend 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, but the same shall not be binding upon the Company unless countersigned by a � Licensed resident agent of the Company. • �C=�%�v--�-�i�vll✓.t�, , _ � � �cre Prerident. , Countersigne i.icensed Resident Agent � Form No. 11451 B Req.8-62 • . t � � , ' . • • • . . , • , • . . . ' , � , � , , � ' ' . . ' , . POLICY CEO 92J. A1•fEtlDt•tEt�'T RIDER � Attached to and formin� Poli.cy}�older , • ' . part of Policy No. � . . , • • • � ' City of St. Paul . ' '- CEO 921 • • In consideration of the payment of tt�e rnont}�J.y p�.,enuums as provided herein, it a.s her�by understood and agreed fi}�at the provisiot�s enti�led Part IX PREMIUi�! PAY1�fENTS and Part X . TERriINA'fl0;d OF POLICY contained in thc abovc men�ioned Policy are de�eted and the following substituted thex�efor: ' • Part IX and X ' " PREMIUth CALCULATION . The monthly premium for the insurance affor.ded hereunder shal�. be cal.culated at �he follo�ain� rates7 ' � $3.00 per month for each Insu•red Person; ' ' ." $6.00 per month fo•r each Insured Person with dependent spousea Except as otherVrise may be specifieally provided, pramiums for insurance hereunder ara payable soJ�ely by the Policyholdero , _ � . The Company reserves the right �o es�ab],ish on any anniversary date of this Policy new pramiLtr�� rates a�t which subsequen�t premiums shall be computed9 provided iche Company gives notice to the Policyholder o= such neFt prernium ra�es beforz January 1 prior �o the anniversary date aL which such new p-rernium rai:es will becor� effec'tiveo , , , � This Rider s�all take effect a� the sarr.V tirr.z and da�e as the Policy fio which it is at�ta�l�edo Nothing he�in .contained shall be held to vary9 al�er9 waive or extend any o� �the terms 9 condi�ionsq provisions9 agrae�nfis or lirnita�ions af -�lie abova mEntioned PolicY9 o�rer �han as above stated, � . . - • . . IN WITNESS F�HEREOr 9 1ch2 STo PAUL FIRE t1ND t�fARIP�E I'tISURAt�� CO�fPAtdY has caused �his Ride•r �c be si�ed by its Prasiden� and S�c•ra�ary, . • , ' ' : ". � • , . � � `�,f��--�.5� �.�,..,.,�,�,� . . `��' sJ �\ ��if" u�—�'�.,� . ` ` \ , ./J �/ Secretary . . � Presiden-t � ' Countersignen ' � • _ �icensed Residenf Agent , . L - - , . . . . � . . . - - . � . �� - . � • . • -� ,. . . ' , . ; . . . • . � Form 1{0� CEO ' � Ed. 11-66 . . - � • . i . � • . . - . � � '. � • � . . . � r •^y[-[-�)�) g� • DUPLIG(�TE TO rRINTER �Nti"���` • , CITY OF ST. PAUL �ILENCIL NO. OFFICE OF THE CITY CLERK • � COUNCIL aESOLUTION—GENERAL FORM PRESENTED BY COMMISSIONER DATE __ RFSOLVED, That pureuant to �he proviaions of reeolution of the Counail, C. F: No. 229337� approved June �0, 1966, the Mayor of the City of Saint Paul is hereby author3zed to egecute, on behalf oP eaid City� an application and rider, a capy of which are attached hereto and incorporated herein by reference, pertainin$ to the City's �oup health policy perta3ning to retired City employees, said agreement being between eaid City and St. Paul Fire and Marine Inaurance Company. COUNCILMEN S�P 2 9196�. Adopted by the Council 19._ Yeas Nays Carlson ��� 2 � 1g6� Dalglish Approved 19— Holland Meredith Tn Favor Peterson �y�r Tedesco �gainst Mr. President, Byrne �zz � - - � . ♦ ' a.+. .a � 1� ! . . . ' � , , � ` ' , • � . ' . POLICY CEO 921 AMENDt�NT RIDER • Attached to and form ng Policyholder " part of Policy No. . � ' � ' City of St. Paul � CEO 921 In consideratian of the payment of the monthly premiums as provid,ed herein, it is hereby understood and agreed that the provisions entitled�Part IX PREMTUM PAYI�NTS and Part X TERMINATION OF POLICY contained in the above mentioned Policy are deleted and the following substituted therefor: ' , Part IX and X PREMIUM CALCULATION The monthly premium for the insurance afforded hereunder ahall be calculated at the following rates? $3.00 per month for each Insured Person; • $6.00 per manth for each Insured Person with dependent spouseo Except as otherwise may be specifi�cally provided, premiums for insurance hereunder are payable solely by the Policyholdero , The Company reserves the right to establish on any anniversary date of this Policy new premium �ates at which subsequent premiums shall be computed, provided the Company gives notice to the Policyholder of such new pre mium rates before .January 1 prior to the anniversary date at which such new premium rates will become effectivea , � This Rider shall take effec� at the same time and date as the Policy to which it is attachedo Nothing herein contained shall be held to vary9 alter, waive or extend any of the terms9 • conditionsg prwisions, agreements or limitations of the above mentioned Policy, other than as abova statedo • . • � IN WITNESS WHEREOF, the STo PAUL FIRE �ND t�lARINE INSURANCE COMPANY has caused this Rider to be signed by its President and Secretary, � . ' • �z�� Secretary_ , � President Countersigned �icensed Resident Agent , • � f . . , . . . . � ` Form Noo CEO � � � , , Ed. 11-66 ; , , , . . , , • � — ---- ----- - -- . , . � ' I ... , , �- - • ,.�' _ -- � ��.:-• . � , . POi,ICY �50. CE092i � • RETTF2EES GROUP ACCIDENT !WD SICI�"1ESS POLICY A CAPITAL STOCK CONIPANY �� �"���:;,� .y l:. L"�ii���..�J'' .. ST. PAUL FIRE AND MARINE �NSUilnr•;ce conni�nr� i�s � INSURAhCE COMP�'�yY ,�"%%:�,:;��.. � FOUNDED 1853 ' � �`` ` '� , (,''", .`. ST. PAUL, MINNESOTA �� � ' � � Sorvinp yo�i niounJ l/iv world...eiound!ho c/ock (Horoin called itio Company) • • The Company a�reE3 with the �olicyholder named in the Schedu�e (harein callad the Folicy- ' holder) to pay benefits to the extent herein provided as to each person insured (hcr�in called the Insured Person) for certain lasses occurring while this Policy is in force �ith respect to such Insured Person resulting from (1) aceidental bodily. injuries occurrir.g to the Insured Person or dependent spouse, if eligible and covered hereunder, (lierei� called • such injuries) or (2) sickness or disease contracted by the Insured Porson or dependen� , spouse, if eligible and covored hereunder, (herein called such sickness) , subject to all the provisions, conditions, limitations� reductions and exclusions of this Policy. SCHEDULE Policyholder's Name and Address • Effec-Cive Date Ters� GITY OF ST. PAUL • July 1, 1966 12 Months N,onthly Premium - $3.00 per month for each Insured Person. $6.00 per month for each.,Insured Person wifih dependent spouse. . This Policy is issued in consideration of the application of the Policyholder, copy o= which is at�tached to and forms part of this Policy, and of rthe payment by the Policyholder of tne . pr�nium ,on behalf of each Insured Person at the rates set forth in the Schedule, to take effect on the date indicated in the Schedule, from which date all insurance years and months snall be calculated, and for the Term indicated in the Schedule. This Policy may be renewed for further consecutive terms' by the Policyholder's payment of the required premiums, subject to the Termination of Policy�provision. Part I ELIGIBILITY . . Each former employee of the Policyholder (age 65 or'�over) who has retired on or oefore I I ' i _ I � , •, ,_ ' ,�f • �'� ° Stctio:is (a) and (b) of this provision, in tho a�;�;re�;ato , shall be subjoct to a �50 caler�dar ycar cash deduc�tible and tho Lifetime A��rogate Amount p��yablo for all periods of �raatrr�ent °or all such injurios or such sickness shall not oxcoed $10 ,000, and provicled alwa�s tha� of such Life�imc Ag�regato Amount, no more than $2 ,500 shall. bo payab].e for all poriods of treat� mont of nervous or mental diseases or deficiencies , psychotic• or psychoneuro-Cic disorders or rnactions. • . . • _, ..-_ Part IV EXTENDED COVERAGE Should -the insurance with respect .to the Insuresd Parson, qr a dependont spou�e of the Insured Person, terminate for any reason except (1) payment of the $10 ,000 Lifetine A��re�ate Amoun�t or (2) failu� of the Insured Parson �o make any requirad premium contribution when due, coveraEe for such person whose insurance �erminated will be extended in the event �he person is totally disabled (unable to perform the dutias of any occupation for wap,e or pro°it, or if th�y havo no occupation, the inability to perform subs-tantially all of their normal � ac�tivi�ties ) at tha time of such termination but such extension of coverage will apply solely to rthe 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 cara of a doctor, bu� not beyond �the and of 12 months following the date such termination occurs. Part V ' • EXCLUSIONS Anything in this Policy to �he contrary notwithstanding, the insurance under this Policy shall no-t cover: � ' (a) in�tentionally self-inflicted injuries, or suicide or any attempt thereat, while sane or insane; nor • (b) expanses incurred for treatment or while confined (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 Administration as a non-paying patient; nor (c) accidental bodily injuries (1) occurring while operating, learnin� to operate, or sorving as a member of the crew �of any aircraft, or (2) which are �tho result o: • . or caused by any act of war, insurrection, or participation in a riot; nor (.d) accidental bodily injuries or sickness for which 'the Tnsured Person is er.�itled to benefit under any Workmen's Compensation, �Employer's L•iability, Occupational Disease � or similar law or act. � Part VI TERMTNATION OF INDIVIDUAL INSURANCE • , _ _._�..; _-=-; ----_---• . � - -..�... `. .. y •^~ r � ,,,i . +. . Part VIII MONTHLY PREMIUM STATEMENT • :;�e Corpany will send to �the Policyholder a monthly premium statement. The Policy;ZOlder ���ill �urnish on �tha Company's forms such information rela-Cive to new Insured Perso;.s ir,sured • and �er.m:.:.a�tions of insurance as is nacossary to enable -L•ho Company.to pr�:�ara such prt:mium . state�ents. Ir any such information is received �oo lato for tho chan�;es �o bo ir,cludod i:� the curn:nt pz�mium statetnont, proper char�;e or cx�edit �herefore will bo �iven ir� a succeading premitun statement. • . Part IX PREAiIUM PAYMENTS All pz�miurru for insurance hereunder, except as othenaisc specifically provided, are pa�abla sol�ly by the Policyholder to the St. Paul Fire and Marine Insurance Corripan�, St. Paul, ;�ii.nr.esota on or beforti the dates upon which they fall due. A Frace period of 30 da�s f.�ill be alloi•red the Policyholder for the• payment of every premium after the fir�t during w:�ic� grace p�riod rthis Policy shall continue in force, except that when ei-ther �he PolicyholZer or the Company shall have given advance written notice of a discontinuance date prior to expiration of tha grace period, this Policy and all insurance provided hereur�der shall ter- minate as of such earlier date. The Policyholder shall be liable to the Cor��any for a �ro- rata prenium for the time the insurance was in forcQ during the grace period. Part X TERMINATION OF POLICY . All ir.surance under this Policy shall terminate at the end of the �race period orhen the r�quired premium is not paid. The Company nay terminate this Policy as of any Policy Anni- versary date by givin� writ�ten notica to the Policyholder at least 30 days prior to such Policy Anniversary, such termination to be effective as of the premium due date next succeedin� tne expiration of the 30 days following tho mailing by the Corr�a�y of the writ�en notica o� terrnination to rthe Policyholder, unless this Policy shall soor,er termir.ate by defaul-t in px�mium payment. The insurance of every Insured Person shall inmedia�ely cease • upon discon�tinuance of this Policy, provided, however, that such termination shall be wi�h- out prejudice to any claim originatin� prior thereto. The Policyholder may terminate this ' Policy on any premium due data. � • Part XI � INDIVIDUAL1C�RTIFICATES The Conpany will issue a Certificate of Insurance to each Insured Person indicatin� �he � , benefits a�forded by this Policy which arc3 applicable to the Insured Pexson together with a srtaterrant as to when and where this Policy or a copy thereof may be seen for inspectior.. GENERAL PROVISIONS � , Entire Contract: Changes: This Policy (including the endorsements and attached pa�ers) , the application of the Policyholder, and the Individual applications of the Persons Ir.sured hereur.der, constitute the entire contrac-C between the parties. In the absence of fraud, . all statements made by �he Policyholder or by any of the Insured Persons shall be deerr.ed rnpresentations and not warranties, and no such statement shall avoid the insurar,ce or reduce the benefits under this Policy or be used in defense of a claim her�under unless i� ia ccntained in a writtcn application signed by the Policyholder or the Insured Per.son, a . CG7�� o� wnich has been furnished to the Policyholdar or the Insured Person or the Insured , Pnrson's benaficiary. No chan�e in this Policy shall be valid until approved by an execu�ive officer o= the Company and unless such approval be endorsed hereon ox attached 'nereto. ,10 a�ent i�as �thQ authority �o chan�o fihi3 Po1'icy or �o vraiva any o� it� provi�ions. ' �otice of Claim: 4lrit-Cen notice of claim must be given to the Company within 30 days arter ;.ha occurrence �of commencement of any loss covered by the Policy, or as soon thereafrter as is r�asona:nly possible. Notice given by or on behalf of the Insured Person or �he ber,eficiary to -the Company at its Home Office in the City of St. Paul, Minnesota, or �to any 13ranch Office of the Conpany, or to any authorized agent of the Company, with information sufficien�t �o idcntifij the lnsured Person shall be deemed notice to the Company. , Claim Forrns: The Company; upon reciept of notice of claim, will furnish �to the claimant such r"ores as az� usualljr furnished by i� for filing proofs of loss. If such for�ns az� :.ot �ur:,i�ned within 15 days after the giving of such notica, tha claimar.� shall be dcer�:d �to hav3 compliod wi�th tha roquiremen�s of this Policy as to proof of loss upon submittin�, wi;.hin �the �irra fixad in this Policy for filing proofs of loss, writton proof covering tho • occurrenco, the character and the extent of the loss for which claim is made: . �_.':f=. . -1 • • r n ♦ ' i� �' ^ ,�r•' , . . < < Proofs oz Loss : jJritten proof of loss must be furnished to the Company at itJ Jaid officc3 in case of ciaim for loss for which this Policy provides any periodic pay�rent co;,�ir.gent upon conrtinuin� loss within 90 days aftar the tormination of tho period for which the Compa.y is liable , and in case of claim for any other �OJJ within 90 days ��ter �:�e date of such loss. Failuz� to furnish such proof wi�thia rthe �tir�e requirod shall not invalidate r,or z�duce �ny claim if it was not reasonablo to �ivc proof within such 'ti�rA, providod such proof is fur:�ishod as soo� as n3asonably possiblo. • Ti7e o� Pay��.ent of Claims : Indemnitios payablo under this Policy for any lass will be paid imreedia�oly upon z�oceip� of due writ�Cen proof of such loss. � Payment of Claims : All indemnitios payabla undar this Policy will be payablo to tho Insured a.�d any accrued indemnities unpaid at the Insured's doath will be pay.ablo to tho esta�ta of �he Ins ure d. Physical Examinations and Autopsy: Tha Company at its own expense shall have the right a;.d o�portuni�ty to exar�ine the person of the Insured 'Pezson when and so often as it may r�asonac�ly require during the pendency of a claim hereundar and to make ar► autopsy in case of death where i� is not forbidden by law. • Legal Ac�tions : No action a�C law or in equity shall be brought to recover o:� this z olicy prior to the expiratioa of 60 days after wri�t�Qn proof of loss has been fur:,ished in accordance with the requirements of this Policy. No such action shall be brought after the expiration of 3 yoars after tha time written proof of loss is rc3quired to be furnished. Assi�nmer.t: No assignmen�C of interest under this Policy shall bo binding upon �the Corpany unless �nd until the original or a duplicate thereof is received at tha Horrs Office of tho Co�npany, which does not assume any responsibility for the validi�ty thereof. Clerical Error: Clerical error upon the part of tho Policyholder shall not prejudice the insurance of any Insured Person nor shall such error continue thQ insurance of ar.y Ir.sured Person beyo:.d tho date i� would othezwise �erminate under �Che terms of this Policy except for such error. PROVISIONS �.QUIRc,D BY LAW TO BE STATEA IN THIS POLICY: - "This Policy is issued under aad in pursuanco of the laws of the S�tate of Minnesota, ralating to Guaranty Surplus and Spacial Reserva Fw�ds." Chapter 437, General Laws of 1909. ' IN WITNESS 4�HERF.OF, the S1'. PAUL FIRE AND MARINE INSURANCE COMPA.�1Y has caused this Policy • to be signed by its President and Secretary, but the same shall no� be binding upon tha Company unless countersigned by a licensed residen�t agent of �he Company. . • ,.: •: , . • � Q . . C�� . _. . � r e e D • . � � \� . Secrotary . � ; ' ' Pzasident : . . , � , • • , Coun�ersigned by � / Y,icensed Residon� Agent ' , , ' .. �� . ' ` � • ';. ' ' .. ., ,'' ; . • ' ' . � . . � . � . . , . • , ,,•�, ;'• • . ' . • S . ' ' , . , , .� • • ' • . • . .• • � •• , � • � . '• .I � • ' , . . ' • . . ' , `'� , , .. � . . , . . •, � ' •