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205570e ORIG11 6L TO CITY CLERK - 205570 CITY OF ST. PAUL COUNCIL INL NO. _ OFFICE OF THE CITY CLERK COUNCIL RFSDU HION— GENERAL FORM PRESENTED BY_/ COMMISSIONER '"���r'�y y "' —� DATE RESOLVED, That the Council of the City of Saint Paul r hereby authorizes the use of Application for Insurance Coverages under the City group program, a copy of which is hereto attached, marked Exhibit "A" and made a part hereof by reference; and be it FURTHER RESOLVED, That the City Clerk is hereby directed to send copies of this resolution to each of the insurance carriers under the Health and Welfare Program. Council File No. 205570 —By Severin A.; Mortinson- Resolved, That the Council of the" City of Saint Paul hereby authorizes the use of Application for Insurance Coverages under the City group pro- gram, a copy of which is hereto at- tached, marked Exhibit "A" and made a part hereof by reference; and be it Further Resolved, That the City. Clerk is hereby directed to send copies of this resolution to each of the insur- ance carriers under the Health and Welfare Program. Adopted by the Council January 16, 1962. Approved January 16, 1962. (January 20, 1962) COUNCILMEN Adopted by the CouncE Ah 16 1962 _19_ Yeas Nays DeCourey JAI 16 1962 Approved 19— Loss In Favor �G- „ -eil., . Mortinson Peterson Mayor Rosen gainst 5M 5.60 2 DUPLICATE TO PRINTER 205570 ' CITY OF ST. PAUL COUNCIL NO. OFFICE OF THE CITY CLERK FILE COUNCIL RESOLUTION — GENERAL FORM PRESENTED BY COMMISSIONER DATE RESQLVED, That the Council of the City of Saint Paul hereby authorizes the use of Application for Insurance Coverages under the City group program, a copy of which is hereto attached, marked Exhibit "A" and made a part hereof by reference; and be it FURTHER RESOLVED, That the City Clerk is hereby directed to send copies of this resolution to each of the insurance carriers under the Health and Welfare Program. COUNCILMEN Yeas Nays DeCourey Loss Mortinson Peterson Rosen l� president, Vavouliy_� SM 5.60 O!W2 — 'r:I Favor F) A gainst JAN 16 1962 Adopted by the Council 19— X` :j9 ? ii 1` ") Approved 19— Mayor HEALTH QUESTIONS Please complete both part A and part B if you are applying for both contributory life insurance and dependents life insurance. PART A — Contributory Life Insurance — Employee Only 1. What is your height? Feet Inches. Weight in street clothes Pounds. 2. Do you know of 'any impairment now existing in your health or physical condition? If "Yes" give particulars 3. Have you consulted a physician for any illness during the last three years? . If "Yes" give particulars as follows: Date Physician's Name & Address Consulted Reason PART B — Dependents Life Insurance 1. Do you know of any impairment now existing in the health or physical condition of your spouse or any of your children? If "Yes ", give particulars 2. Have your spouse or any of your children consulted a physician for any illness during the last three years ?_. If "Yes ", give particulars as follows: Name and Relationship Date of Dependent Physician's Name and Address Consulted Reason The information on this form is given to obtain insurance under the City of St. Paul Employees Group Plan' and is complete and true to the best of my knowledge and belief. Igor the purpose of permitting determination of insurability, I hereby expressly waive, on behalf of myself and of any person who shall have or claim any interest in any insurance issued under said policy all provisions of law forbidding any physician or other person who has attended me or any of my dependents or who may her'eaf`ter attend or examine me or any of my dependents from disclosing any knowledge or information thereby acquired by him and I expressly authorize such physician to make such disclosures. Date Signature of Employee A, In the event I am temporarily laid off or granted leave of absence without pay and reinstated to employment within six months, I request and authorize my employer, the City of Saint Paul, to deduct from my wages a sum sufficient to pay premiums necessary to immediately reinstate my optional and dependents' coverages which were in effect prior to my layoff or leave of ab- sence. I understand that I may rescind this authorization by written notice given to The Minnesota Mutual Life Insurance Company, Victory Square, Saint Paul 1, Minnesota, at any time prior to the date of reinstatement. SIGNATURE OF EMPLOYEE DATE B. In the event I am temporarily laid off or granted leave of absence without pay and reinstated to employment within six months, I do not wish to participate in any optional or dependents' cover- ages excepting only the City - purchased coverages for which I am eligible. However, I reserve the right to make any changes in coverages which are offered at the time of annual re- solicitation. SIGNATURE OF EMPLOYEE — DATE CITY OF ST, PAUL, No. ;0 OFFICE OF THE CITY CLERK COUNCIL RESOUTION—GENERAL. FORM PRESENTED BY COMMISSIONER--/ _DATE RESOLVED, That the Council of the Ci,�;y of Saint Paul hereby authorizes the use of Application for Insurance Coverages under the City group program, a copy of which is hereto attached, marxed Exnibit "A" and made a part hereof by reference; and be it FURTHER RESOLVED, That; th City is iiereby directed to setid copies of this resolution to each ai tne insurance carriers under tne Health and Welfare Program. COUNCILMEN Adopted by the COUn4AX.1 9 196t2 19 Yeas Nays DeCourcy .1_4,4 1 6 1962 Approved Loss --In Favor Mortinson Peterson Against Mayor Rosen �.ent—,tfl�tt!T- -.14 F.150 >� 2