HomeMy WebLinkAbout550004.tiff IN THE MATTER OF ADOPTION OF PROPOSED
GROUP INSURANCE POLICY FOR COUNTY EMPLOYEES:
WHEREAS, seventy-eight per cent (76%) of the Weld County Employees
have expressed their desire to the Board for a different group insurance policy,
and
WHEREAS, the Board has considered a proposed group insurance policy
carefully and fully, and
WHEREAS, the employees have indicated their desire to change to the
proposed group insurance policy plan, and
WHEREAS, this Board has concurred to the thinking of the employees
and believes it to be to the best interests and welfare of the County by the
adoption of the proposed plan.
NOW, THEREFORE, BE IT RESOLVED by the Board of County Commissioners
of Weld County, Colorado that the group insurance policy plan which was pro-
posed to the employees by the local representative of the Pacific Mutual
Insurance Company, be adopted and be effective as of April 1 , 1955.
The above and foregoing resolution was, on motion duly made and
seconded, adopted by the following vote:
AYES: .L /7 41 fd r-Z1.
Al
HE BOARD OF CCIJNT T Y`COMMISSIONERS
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MELD COUNTY, COLORADO
MARCH 24, 1955
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IN THE MATTER OF ADOPTION OF
PROPOSED INSURANCE POLICY FOR
COUNTY EMPLOYEES:
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Application to-Pacific Mutual Life Insurance Company
LOS ANGELES, CALIFORNIA
by 1vield_County, Co1or%u' Employer
(GIVE FULL NAME AS IT IS TO APPEAR IN GROUP POLICY)
of r!nurt 1;1011F(9 Ae1 y, Colnrtudn
STREEMBER
for a Policy or Policies Tof�Group Insurance to provide the Benefits indicated below.This application includes the following
subsidiary or affiliated companies owned or controlled by the Employer: 16th St. & 17th Ave.
weld County GAnr.,rA.l )Io pi al located at GrAe)r'y C:n1 weed',
16th St. & 17th Ave.
Eeld County Health Department located at Qrealay, CElorade
1027 16th St.
geld County Public 1e].f'are Department located at fireelasy, t o1 wen tin
1320 8th Ave.
If,eld County Libran, located at Greeley, Calorac;^
Contrib.12 Non-Contrib. ❑ Contrib. ❑ Non-Contrib. O Contrib.❑ Non-Contrib. ❑
Insurance Paid—up Term Life Accidental Death Disability
Classification Insurance and Dismemberment
Principal Sum Weekly Benefit
All employees ti 1,000.00
❑Non-Occ. ❑ 24-Hour
❑ DISABILITY BENEFITS Benefits commence: flay accident; day sickness
(Employees only) Maximum Period Weeks 6-Weeks'Maternity Benefit: O Yes O No
Max.Daily Maximum Max.
❑ HOSPITAL ❑ EMPLOYEE: ❑ Reimbursement Benefit$ Misc.Expense $ perio' days
EXPENSE Maternity Benefits:❑Included O Excluded.Maximum Maternity Benefits
BENEFITS Max.Daily Maximum Max.
❑ DEPENDENT: ❑x Reimbursement Benefit', Misc.Expense$ Period days
Maternity Benefits:O Included O Excluded.Maximum Maternity Benefits
O SURGICAL
❑ EMPLOYEE: Maximum Benefit R obstetrics O Included O Excluded
BENEFITS ❑ DEPENDENT: Maximum Benefit$ Obstetrics ❑ Included ❑ Excluded
❑ Comprehensive O In Hospital O Total Disability
❑ MEDICAL ❑ EMPLOYEE: Maximum Per Visit:$ Office,$ Hospital,$ Home
BENEFITS r Benefits Commence: Visit on account of accident Visit on account of sickness
❑ DEPENDENT:{❑ Comprehensive O In Hospital Max.Per Visit$ Office,$ Hospital,$_dome
Benefits Commence: Visit on account of accident Visit on account of sickness
❑ DIAGNOSTIC X-RAY AND O EMPLOYEE: O Scheduled O Non-scheduled Maximum$
LABORATORY BENEFITS ❑ DEPENDENT: O Scheduled O Non-scheduled Maximum a
❑ SUPPLEMENTARY ACCIDENT BENEFITS EMPLOYEE:Maximum$ DEPENDENT:Maximum$
❑ POLIOMYELITIS BENEFIT EMPLOYEE:Maximum$ DEPENDENT:Maximum
(In lieu of all other benefits for Hospital,Surgical,Medical and Diagnostic Expenses)
1. State any special requests Weld County General Hospital new impioyeee mast be in
r
a„m,r ace
2. The Medical Expense insurance is contributory:for Employees ❑ yes O no; for Dependents O yes 9 no.
3. New Employees must be in continuous service_- l) months before they become eligible for insurance.
[Does this probationary period apply to employees in service on the effective date of the Policy or Policies? $, -
)mployeee paid on the hourly basis,. yes or no
4. Employees not eligible pstrt time employees end seasonal employee--.
5. It is requested that the Policy or Policies become effective on April 1, 9 -with premiums
payable gwirterlyn gdvance., for first payment. then semi—annually thereafter.
If issued on the non-contributory basis,the Employer agrees that the employees will make no contribution toward the
cost of the insurance,and that all eligible employees will be reported to the Insurance Company for coverage as they become
eligible.If issued on the contributory basis,the Employer agrees to give all eligible employees an opportunity to subscribe
for the insurance and further agrees to pay the required premium to the Insurance Company and deduct employee contribu-
tions from their salaries or wages.It is understood that no policy will be issued on the contributory basis until at least 75%
of the eligible employees have subscribed to the plan,and that coverage with respect to dependents shall not be issued until
at least 75%of the eligible employees having dependents have subscribed to the plan for themselves and their dependents.
It is agreed that no insurance shall become effective on any person unless such person is then a bona fide employee of
the Employer,regularly performing the duties of his occupation.
Signed at, Greel or State otolorade ,this S0 day of mare!:
Waiter I,, BAir E fie field County, Colorado.
Soliciting Agent ]o B Zh Wimp of the Nemec/
Amount of Advance Payment$/4e'5 5
GR31 BTitle
aCounty Cgptmissioners
PACIFIC MUTUAL LIFE INSURANCE COMPANY,Los Angeles,California
RECEIPT FOR ADVANCE PAYMENT
RECEIVED FRO'--,-0�(��t' [-/X4¢+ he sum of
3O
.m advance payment toward the first premium or premiums on the Group Insurance applied for on
the application bearing the same date as this receipt.If no policy or policies are issued,the amount here receipted for shall
be returned.
Dat /1/—Q - /9S Agent 5
GR 31B
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