HomeMy WebLinkAbout770759.tiff RESOLUTION
RE: AMENDMENT NO. 7 TO GROUP POLICY NO. GM-8864 ISSUED BY
PACIFIC MUTUAL LIFE INSURANCE COMPANY TO THE POLICY-
HOLDER, WELD COUNTY, COLORADO.
HERETOFORE, Weld County, by Resolutions have entered into
a contract with Pacific Mutual Life Insurance Company for group
insurance covering Weld County employees , under the group in-
surance policy and amendments thereto, to-wit:
Group Policy No. GM-8864 together with amendments
1-6 thereto, and
WHEREAS, the Board of County Commissioners of Weld County,
Colorado, believe it to be in the best interests of the County
to accept the aforementioned Amendment No. 7 to the aforementioned
group policy as proposed, covering said group policy as hereinabove
mentioned and on the basis as recited herein.
NOW, THEREFORE, BE IT RESOLVED by the Board of County
Commissioners of Weld County, Colorado, that the hereinabove
mentioned Amendment No. 7 submitted by Pacific Mutual Life In-
surance Company amending group policy No. GM-8864 , a copy of
which is attached hereto and made a part hereof by reference,
be and hereby is approved.
BE IT FURTHER RESOLVED that the Board be and hereby is
authorized to execute said Amendment No. 7 to the aforementioned
group policy, to-wit:
GM-8864, as submitted, and to make it effective nunc
pro tunc to January 1, 1977 .
The above and foregoing Resolution was, on motion duly made
and seconded, adopted by the following vote on the 7th day of
March, A.D. , 1977.
The above and foregoing Resolution was read into the record
and signed on the 7th day of March, A.D. , 1977.
BOARD OF COUNTY COMMISSIONERS
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WELD COUNTY, COLORADO
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ATTEST: f 1 n i!' '. ,„,,,,,..-S1-2.c °na a I
0 9Weld County Clerk and Recorder l l 1 tc % -' > Pe
and. Clerk to the Beard [
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Deputy County Clerk
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County Attorney 770759
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POLICYHOLDER'S COPY
AMENDMENT NO. 7
Attached to and part of Group Policy No. GM-8864 by and between Pacific Mutual Life Insurance
Company, and the Policyholder,
WELD COUNTY, COLORADO.
The Policyholder and Pacific Mutual hereby agree that the policy is amended, as of the effective date
stated on each amended page, by deleting from the policy the page or pages thereof listed under
Column I and inserting into the policy the attached page or pages listed under Column II, each marked
by "Amendment No. 7 effective January 1, 1977".
COLUMN I - PAGES DELETED COLUMN H - PAGES INSERTED
11B-3-c 11B-3-c
IN WITNESS WHEREOF, the parties hereto have, by their duly authorized representatives set their hands
on the date set forth beneath their respective signatures.
POLICYHOLDER PACIFIC MUTUAL LIFE INSURANCE COMPANY
Signature o Officer President
TITLE Chairman Pro Tem /0,44.40'd 6144/0_4a.
Board of County Commissioners Secretary
DATE March 7. 1977 ATTEST 14421.(4"."/ I"""`�
.. Registrar
VF `--- (yv-�.1. �� -"'"`.at? DATE 7"4.4.1 / ( / // / 7
GF(. 8 F
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COMPREHENSIVE MAJOR MEDICAL EXPENSE BENEFITS (Continued)
SCHEDULE OF BENEFITS
Classifications of Individuals
One class applicable to all
Hospital Expense Benefits
Daily Service Charges
-maximum eligible charges for each day in which the covered person occupies:
(a) hospital accommodations other than an intensive care unit the hospital's charge for semi-
private accommodations not to
exceed $76
(b) an intensive can unit
(including coronary, special, and respiratory care) 250% of charges specified in(a)
above for the first ten days in
such unit and 100%thereafter •
(c) accommodations in a convalescent hospital 503 of charges specified in(a)
above
All Hospital Charges(including daily service charges)
-maximum eligible charges during any period of confinement 100% of the first $5,000 of eligible
charges incurred during a calendar year,
80% of the next $5,000 of eligible
charges incurred during that year, and
100% of the balance of eligible charges
incurred during the same calendar year.
The eligible charges used in determining benefits under this section are subject to the cash deductible described in the
section entitled "Cash Deductible", except eligible charges incurred for treatment of an illness on an out-patient basis or
for treatment of bodily injuries sustained in an accident.
GR-231(8864) AMENDMENT NO. 7 EFFECTIVE JANUARY 1, 1977 Page 11B-3-e(2)
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