HomeMy WebLinkAbout20033450 RESOLUTION
RE: APPROVE DENTAL EMPLOYER PARTICIPATION APPLICATION AND AUTHORIZE
CHAIR TO SIGN - COMPANION LIFE INSURANCE COMPANY
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 Board has been presented with a Dental Employer Participation Application
between the County of Weld, State of Colorado, by and through the Board of County
Commissioners of Weld County,and Companion Life Insurance Company,commencing January 1,
2004, with further terms and conditions being as stated in said application, and
WHEREAS,after review,the Board deems it advisable to approve said application,a copy
of which is attached hereto and incorporated herein by reference.
NOW,THEREFORE, BE IT RESOLVED by the Board of County Commissioners of Weld
County,Colorado,that the Dental Employer Participation Application between the County of Weld,
State of Colorado, by and through the Board of County Commissioners of Weld County, and
Companion Life Insurance Company be, and hereby is, approved.
BE IT FURTHER RESOLVED by the Board that the Chair be, and hereby is, authorized to
sign said application.
The above and foregoing Resolution was,on motion duly made and seconded,adopted by
the following vote on the 22nd day of December, A.D., 2003.
BOARD OF COUNTY COMMISSIONERS
_D0 / WELD COUNTY, COLORADO
ATTEST: Le M/0 V' �W% EXCUSED
ti 4) D vid E. Long, Chair
Weld County Clerk to t B.: 1
2r1 ritto,61;z?
Robert D. sden, Pro-Tem
Deputy Clerk to the .ar. : (1~\
• Vc1 M. J. eile
AP AS Ti ��
ISd4
Glenn Vaad
Date of signature: ---1
2003-3450
PE0021
`® Companion Life DENTAL EMPLOYER PARTICIPATION APPLICATION
Po.boxiooloz Columbia,SC 29202-3102 FOR THE JOINT EMPLOYER GROUP INSURANCE TRUST
EMPLOYER(APPLICANT)INFORMATION, (Please__Print or Type)
.It Legal Name of Employer: W e-id Gala\t'��1 6o Verr\rv" s ,€
A.—Address: Q« C0 ` Sfrecl- — P0Cjc"t,c7SKCity: 5reelei State:�Zip: D&3t
RI—Telephone:( q 70 ) 36-49 -I-I CA0O K`I231 Contact: J Q U.I e t R- \ cu, rr (,n Title: PQc r'di JpQ,c i&&(1st
(Person to contact concerning coverages)
No.of Eligible Employees: 1 ,i or—.- No.of Eligible Employees Enrolled:
Effective Date Requested: Ste- X, 7e..,`1' SIC Code and Nature of Business:
(The requested effective date must be the first day of a calendar month.)
How many years in this business? I"51.c How many years at this location? I—)I xy
tTax I.D.No.: a4—(D000 g 13 No.of Family Members in Organization: 1-0),&,.
PLAN REQUESTED: Voluntary Indemnity Group Dental Program.
In order for Companion Life to determine whether or not Takeover Benefits are mo to be included,the
the following must be provided:
o�t� —rt,L>.�K cY
a. Name of Prior Carrier: tt
b. Effective Date of Prior Plan: I 1 I 1 S 5 c. Termination Date of Prior Plan: t I I /v'4
The employer must also submit a copy of(1)the prior carrier's most recent billing statement;(2)a certificate or letter of acceptance
that shows the effective date of the prior plan;and(3)the prior carrier's certificate,booklet or schedule of benefits.
Coverage Is For: ❑ Employees Only $Employees and Dependents ❑ Employees and Dependents with Ortho
(Employment Waiting Period: ❑ 1 Month X Other: (s- cR mnrl-h 4 ilk,tx:.V one, AA j pui ca W�t'I'ke_d
(No elimination period applies to those employed on the effective date.) J
(Coverage following completion of the wailing period will be effective on the first day of a calendar month only.)
The employer agrees to contribute the following percentages or monthly dollar amounts toward the overall cost of dental insurance:
For Employees: ❑ None ❑ %of single-employee cost ❑ $ t
For Dependents: ❑ None ❑ %of cost ❑ $ I I
FRAUD WARNING:Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or a
statement of claim containing any materially false information or conceals for the purpose of misleading information concerning any fact material
thereto commits a fraudulent insurance act,which is a crime and subjects such person to criminal and civil penalties.
Participation Agreement(Administered and underwritten by Companion Life Insurance Company)
The Employer hereby applies for Group Insurance Benefits as set forth in the above"Dental Employer Participation Application for the Joint Employer Group Insurance
Trust"and subscribes to the Agreement and Declaration of Trust. Name of Trust: The Joint Employer Group Insurance Trust
It is understood and agreed by the undersigned that the Trustee is not an insurer,nor does the Trustee have any obligation under any policy of insurance and that all claims
for and benefits provided by insurance being applied for herein shall be made to and payable by the Insurance Companies issuing group policy(ies)to the Trustees,but only
to the extent and in strict accordance with the provisions of such policy(ies).The Trust agreement and the group policy(ies)held by the Trustee are available for inspection
during ar business hours by the Participant at the office of the Administrator,Companion Life Insurance Company,located at 7909 Parklane Road,Suite 200,
Columb 223-566
Employer Group No.:
(Signature o mp er/Applicanq FOR HOME OFFICE Takeover Benefits: ❑Yes ❑No
USE ONLY
(Date) Accepted by Companion Life Effective:
"C.'.7a
i /(Signature olResiqe,ntog rqer), (Date) By:
P Sor.-.c2 7Ie.\/.c:.?t
Print Agent's/Broker's Name License No. (Title) (Date)
Form d 95123(C0NV) - - ----
2003-3450
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