200983I F
ORIGINAL TO CITY CLERK `
PRESENTED
COMMISSI
CITY OF ST. R
OFFICE OF THE CIl
Council File No. 200983 —By Bernard
T. Holland, by request—
Whereas, Many employees of the
City of Saint Paul are subject to tem-
porary layoff or leave of absence, and;
Whereas, Such employees often, suffer
a lapse of time in the reinstatement
of their optional and dependent(s)
group coverages under the City health
and welfare program, and it has, there-
fore, become desirable to modify the
application covering said (Troup cover-
ages;
Now, Therefore, Be It Resolved That
.t�e.,atta ^tied ..:en?l)i °a`��n �-o•trtied ?:+«_
200983
WHEREAS, many employees of the City of Saint Paul
are subject to temporary layoff or leave of absence, and;
WHEREAS, such employees often suffer a lapse of
time in the reinstatement of their optional and dependent(s)
group coverages under the City health.and welfare program,
and it has, therefore, become desirable to modify the appli-
cation covering said group coverages;
NOW, THEREFORE, BE IT RESOLVED that the attached
application marked "Exhibit A" and made a part hereof,
wherein temporarily laid off employees,,or those who are
granted leave of absence may make prior application to have
all of their group coverages reinstated promptly upon their
return to work, or to have only their basic coverages so
reinstated, is hereby in all things approved and adopted.
BE IT FURTHER RESOLVED, that the City Clerk is
directed to send copies of this resolution to each of the
insurance carriers under the Health and Welfare program.
C-u-g 2 8 1961
COUNCILMEN Adopted by the Council 19—
Yeas Nays ,
DeCourcy FEB
Holland Appr ed 19.—
Loss
Mortinson Tn Favor `
Peterson 1 Mayor
rr— � Against PUBLISHED — l0� //
Qse Mr. President, Vavoulis
am a -eo 2
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EXHIBIT A
�
4�3
CATS
BEREFlC1ARr INIYgN PIMP NAwt w NARRIBO WOMAN) RELAT'mm"IP OAl
{ THE 8WEF1d ARY MWCMATOM MADE ON TWS CARD HALL rPPLY TO LL Uzi IWjrA cx UMCBR THE
NDTtt GROUP PLAN. 1J THE Cfngert JARY DEsuMTM FOR LIFE IKstXWW t PlRdifl(TLY IN ffaftcE Is TO APPLY
TO INnXVJ X APft= POR ON THIS CAPA DO "ar cm4putTE Tn3 BOCTIOra
R
As AN ftoLoy 2 Or T►1E QTY OF ST. PAUL A- Mill -E FOR TIE StMr TS OFFOMM UHOFJI CONTRACTLOF OROII►
VALE L_J WARMED
"i'"""CE IsMAO TO MY EI`LOYIOR. 1 HaESY APPLY FOR. ON MMMST
OW4t RI. WX" OF SMO D+ XZMTS AS
PEIAALE
❑ SIMLE
f��
1(3
"at INDICATED EY•A• OR � I• IN YHE BOXES SET OPPOSTE THRRETO, AS rO L LOR3e
R'
s11001fYD❑
QV4RCIID
ACCIOENT E SICKNES4
1 z
;..s
i
E
ACCIQtNY f SfrUET INOMiIR.Y INOERKTT
'MAJOR SUROIC Ai - MEOC1L
THE MINNESOTA MUTUAL LIFE 11RAUEAHCE CO. g w
ST. PAU 1. PURE & IIARM IM1.11RAR t CUMPAW
SUNGfAL i IN-HOSPITAL INIMICAL EXP=ZX _
!NSA
I LIFE - ACCIDENTAL 01ATH ■ OIOiEMs KfMCNT
AOMOEHT k SICKNESS MONTHLY INDEM. EMB
j,S,OE
• *OTAL
NONCONTRIBUTORY &TOGO 06-0
CONTRIDUToRY AMOUNT S 13
=GMT t VC-r lS3%MNTHLY b;CC}I Us
-r
ACCtmw E SICJU1EA3111DNTHLY /NOUN. ICI
S
MDARESOTA NoiPITAL SEkVICE ASSOQATIOH {SLUE CROSS)
MIRMCAL f IN-HOSPITAL M4CICAL ZzPE.TI+E
HOSPITAL BENEFITS-CONPREH Egg VIE-US DAYS
EItPLOYAU ONLY
.❑ ��r,
' CAPLOYEE ONLY �y
S 6 ,. r ❑
DEPENDENTS ONLY
❑ JLgC.
f❑
DEPENDENTS ONLY i„I %(!- 4.r ❑
(LlJ
.ESIPLOYEE AND OEPENOENTS
❑' /n
yj
17fPLOYEE S DEPENDENTS Z % G(If ❑
MAJOR SURGICAL i W:MCAL EXPENSE
' CROUP HO: f vowwCARr�ucCROSS,��VE -
flAPLOTECaNLY
❑
p
NO.
EMPLOYEE S DEPENor"71
❑ 11EQ
c'�'.
CROUP INSURANCE APPLICATMIM CAED -CITY Or ST. PAUL
OATCOF
FILLED III SYT014t
I
X
APi'IIGMTION
PATE A1101M
LIFE
f1E!
A t
YOGI
TOTAL
3101NATURE
HITK03
. RAE` OCPARTMENT �
1 KEREBY AUTHORIZE MY EMPLOYER. THE CITY OF ST. PAUL, TO'DEOl1Ct PROM NY PAY EACH MoNT/ THE AgpCENT OF _ 1W1 {h•iC4 is
REQUIRED TO CONTINUE NI FORCE mx BEfNEFIT S APPLIED roR, OIRCttANGICD.'ON THIS DATE AMC ANY I-P . ILTI PO.1 r*.- yfOU:'3A'Ctr'f Yt
I •MOT CNANGED, ISSUEO UNDER INA3TER CONTRACTS WAITT@H BY T1EIMINNE00TA!RITUAL LIFE IU=!RAHCE COWA -tY, C. HAUL F'N7 AN7
IKARINE INSURANCE COMPANY AND MSKI(K4OTA HO3PITA1, SERVICE ASs'OCIATION. AN•r opt ALL, SUBJECT TO SM RIGMT. WY WVTTEN h"'."1 Sty
lb REVOKE TtIS AUTHORIZATUXI AT ANY TIME MITH NESPCCT TO PRETAUSO: NOT YET DUE POR ANY OR ALL EE•A.- _,FITS HCR =1M rgPI..CO
PM CHANGED, OR CONTI*= IN FORCE RITHOUT CHANGE. NY EMPLOYER 1s AUTmoR1ZS0 To "wm AOJ'JSTMCNTS IN FRC,NIzw >J
KADE PHOM TIME TO TIME BY THE INSUFMRS IN MRAIQNO THE O= DYCTIONS K67tEtR AUTHORIZED.
�(Sajar, Ey"se rl Olt )
Td
at rNN.Lto IN i7IIN"en WHEN THERE 1S CHANGE BEwvIT PC.E Lm
1H EXIST" PEDUCTM
TOTAL Ted 100MOTA MUTUAL LWE 413UEAWC1 OOSWAHT
1 SfML
TtONCORTJUOUTORY SIOM LIFE f ACRD
LIFE i ADAO S
COKTRtBUTORY pra i AO &D
_ fN0{VIOUAL POLICY
M";K9 OTA HOSPITAL LE MME AWXIATWH
TT P Fill
HOSPIT'AN. EXPENSE _..
ACCIOENT E SICKNES4
SURGICAL M OICAL
ST, PALL. Fit AXD VAR= It4> 2AwE CDC,�IA ff.
ACCIQtNY f SfrUET INOMiIR.Y INOERKTT
'MAJOR SUROIC Ai - MEOC1L
SUNGfAL i IN-HOSPITAL INIMICAL EXP=ZX _
!NSA
MAJOR SURGICAL f IM%WCAL EXPLNdE
HOMTAL EXPENSE
• *OTAL
DATE
IIM1N w4Y. t-sM
IROIIATURR _
WAIVER
1 DO NnT WANT TO INSURE MYSELF FOR THE FOLLOWING COVERAGES:
200983
1 DO NOT WANT TO INSURE MY DEPENDENTS FOR THE FOLLOWING COVERAGES.
SIGNATURE OF EMPLOYEE
DATE
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 gages 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
absence. I understand that I may rescind this authorisation 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 pix
months, I do not wish to participate in any optional or de-
pendents' coverages 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