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RESOLUTION
RE: AUTHORIZATION FOR CHAIRMAN TO SIGN PACIFIC MUTUAL AMENDMENTS.
WHEREAS, the Board of County Commissioners of Weld County,
Colorado, pursuant to Colorado statute and the Weld County Home
Rule Charter, is vested with the authority of administering the
affairs of Weld County, Colorado, and
WHEREAS, the Weld County Finance Officer has informed the
Board of County Commissioners of three (3) amendments to Pacific
Mutual Insurance, which include the following:
1) Amendment to GL-A3, increase of life insurance.
2) Amendment to GR-A3, accidental death and dismemberment.
3) Amendment to GM-ALL, room rate increase.
WHEREAS, the Weld County Finance Officer has requested that
the Board of County Commissioners authorize its Chairman to sign
said amendments.
NOW, THEREFORE, BE IT RESOLVED by the Board of County Com-
missioners of Weld County, Colorado that the Chairman of the
Board be, and hereby is, authorized to sign said amendments to
Pacific Mutual Insurance.
The above and foregoing Resolution was, on motion duly made
and seconded, adopted by the following vote on the 26th day of
March, A.D. , 1979.
�y � BOARD OF COUNTY COMMISSIONERS
ATTEST: / �Q uuf Q /1MX1c� W LD COUNTY,
Weld County Jerk and Recorder
a.• Clerk to the :oa
y:
l / -47/€47.-1 A end-"7 4>
--Deputy County C r 9Lt )
AP' D AS TO FORM:�
County Attorney
Date Presented: March 28 , 1979
790890
• AMENDMENT NO. 11 POLICYHOLDER'S COPY
Attached to and part a 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. 11 effective January 1, 1979
COLUMN I- PAGES DELETED COLUMN II- PAGES INSERTED
11B-3-c (2) 11B-3-c (2)
NOTWITHSTANDING ANY CONTRARY PROVISION OF THE POLICY, THE INCREASE IN BENEFITS EFFECTED BY THIS
AMENDMENT SHALL NOT APPLY TO ANY INSURED PERSON (EXCEPT A PERSON COVERED AS A DEPENDENT)IF HE IS
ON LEAVE OF ABSENCE FOR ANY REASON OTHER THAN VACATION AND UNLESS HE ACTUALLY IS PERFORMING THE
USUAL AND CUSTOMARY DUTIES OF HIS JOB ON A FULL TIME BASIS ON THE DATE THE INCREASE IN BENEFITS
WOULD OTHERWISE TAKE EFFECT AS TO HIM. IF AN INSURED PERSON IS NOT ACTIVELY SO EMPLOYED ON A FULL
TIME BASIS ON THE EFFECTIVE DATE OF THE BENEFIT INCREASE, SUCH INCREASE SHALL BE DEFERRED AS TO HIM
UNTIL HE HAS SUBSEQUENTLY COMPLETED TWO CONSECUTIVE, CONTINUOUS WEEKS OF FULL TIME EMPLOYMENT
IN AN ELIGIBLE CLASS.
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
em" "/"46145"nrb44.
Signature of Officer President
Weld County, Colorado
Chairman, Board of County Commissioners r
TITLE
Secretary
DATE -�GJ — 7 2 ATTEST
Registrar
DATE 7
GR-4829
•
COMPREHENSIVE MAJOR MEDICAL EXPENSE BENEFITS (Continued)
SCHEDULE OF BENEFITS
Classification 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 accomodations not to
exceed $95
(b) an intensive care 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 50%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. 11 EFFECTIVE JANUARY 1, 1979 Page 11B-3-c (2)
AMENDMENT NO, 3 POLICYHOLDER'S CON
•
Attached to and part c: Group Policy No. GL-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, 3 effective January 1, 1979 ,
COLUMN I- PAGES DELETED COLUMN U- PAGES INSERTED
7-1 7-1
NOTWITHSTANDING ANY CONTRARY PROVISION OF THE POLICY, THE INCREASE IN BENEFITS EFFECTED BY THIS
AMENDMENT SHALL NOT APPLY TO ANY INSURED PERSON (EXCEPT A PERSON COVERED AS A DEPENDENT)IF HE IS
ON LEAVE OF ABSENCE FOR ANY REASON OTHER THAN VACATION AND UNLESS HE ACTUALLY IS PERFORMING THE
USUAL AND CUSTOMARY DUTIES OF HIS JOB ON A FULL TIME BASIS ON THE DATE THE INCREASE IN BENEFITS
WOULD OTHERWISE TAKE EFFECT AS TO HIM, IF AN INSURED PERSON IS NOT ACTIVELY SO EMPLOYED ON A FULL
TIME BASIS ON THE EFFECTIVE DATE OF THE BENEFIT INCREASE, SUCH INCREASE SHALL BE DEFERRED AS TO HIM
UNTIL HE HAS SUBSEQUENTLY COMPLETED TWO CONSECUTIVE, CONTINUOUS WEEKS OF FULL TIME EMPLOYMENT
IN AN ELIGIBLE CLASS,
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
sleag124
Signature of Officer President
Weld Cornrty, Co/orado
Chairman, Board of County Commissioners /'
,/�
TITLE -- -
Secretary
5 - 77DATE � .� ATTEST
Registrar
DATE 3— 2 _ 11
GR-4829
LIFE INSURANCE FOR INDIVIDUALS (Continued)
SCHEDULE OF BENEFITS
BASIC LIFE INSURANCE
Classification of Individuals - Amount of Basic Life Insurance
Class 1 Individuals who have been employed
by the Policyholder for at least five years $10,000
Class 2 Individuals who have been employed by
the Policyholder for less than five years $ 5,000
Anything hereinabove to the contrary notwithstanding:
A. The amount of basic insurance in force on the life of an Individual who is 65 years of age but under 70 years of age on
the date he becomes insured under this policy or who attains the age of 65 years while insured hereunder shall not exceed
$2,500.
B. The amount of basic insurance in force on the life of an Individual who is 70 years of age or over on the dare he becomes
insured under this policy or who attains the age of 70 years while insured hereunder shall not exceed $1,000.
C. Any reduction in the amount of insurance in force on the life of an Individual who attains age 65 or age 70 while insured
hereunder shall become effective on the policy anniversary date coinciding with or next following the dare the Individual
attains said age.
SUPPLEMENTAL LIFE INSURANCE
Classification of Individuals Amount of Supplemental Life Insurance
Class 1 Individuals whose basic monthly salary is
$500 or over $5,000
Class 2 Individuals whose basic monthly salary is
less than $500 $2,500
Anything hereinabove to the contrary notwithstanding:
A. The amount of supplemental insurance in force on the life of an Individual who is 65 years of age but under 70 years
of age on the date he becomes insured under this policy or who attains the age of 65 years while insured hereunder shall
not exceed 50%of the amount of supplemental life insurance as determined from the above Schedule of Benefits.
B. Any reduction in the amount of insurance in force on the life of an Individual who attains age 65 while insured hereunder
shall become effective on the policy anniversary date coinciding with or next following the date the Individual attains
said age.
GR-205 (8864) LIFE INSURANCE FOR INDIVIDUALS Page 7-1
AMENDMENT NO, 3 EFFECTIVE JANUARY 1, 1979
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