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