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Home My WebLink About560006.tiff IN THE MATTER OF RESOLUTION REGARDING GROUP LIFE POLICY NUMBER GP-3651: WHEREAS, in Weld County some county employees have given long and faithful service to Weld County, and WHEREAS, some of these older employees are compelled because of sickness or injury resulting from age cease active work. NOW, THEREFORE, BE IT RESOLVED, that all employees covered under Group Life Policy Number GP_3651 with Pacific Mutual Life Insurance Company, the insuror, and Board of County Commissioners of Weld County, Colorado, as Policyholder, who have had 20 years of continuous service prior to termina- tion of employment and who have attained the age of 75 years before term- ination of their employment and the termination of whose employment was on account of sickness or injury shall be eligible for continuation of his insurance in accordance with ARTICLE III Section 1 of said Group Policy. The above and foregoing resolution was, on motion duly made and seconded, adopted by the following vote: AYES: „//4-2-7-.....4,„- 'M 4 / ( / t THE BO 0 UNTY COMM SSIONERS WELD NTY, LORADO DATED: APRIL 12, 1956. 56e): o(; File p-7 No. g IN THE MATTER OF RESOLUTION • REGARDING GROUP LIFE POLICY cm NUMBER GP-3651: /7G APr::?Crrli the / -- day of i 2 1-A 7 2cc,J ,:cu ,.;,,ua?ssion Group Policy No. GP-3651 PACIFIC MUTUAL LIFE INSURANCE COMPANY 0 (Herein called the Insurance Company) This policy shall be construed in accordance with the laws of Colorado, where it is delivered, and is a contract between the Insurance Company and THE BOARD OF COUNTY COMMISSIONERS OF WELD COUNTY, COLORADO, ; (Herein called the Policyholder), covering certain employees of the Policyholder at: WELD COUNTY GENERAL OFFICES, WELD COUNTY GENERAL HOSPITAL, WELD COUNTY HEALTH DEPARTIeNT, 5 WELD COUNTY LIBRARY, WELD COUNTY ROAD AND BRIDGES, and WELD COUNTY WELFARE DEPARTMENT (Herein collectively called the Employer). '1 The Insurance Company HEREBY AGREES TO PAY, immediately upon receipt of due proof ; of the death of any employee who is insured under this policy, the amount of in- ! surance specified in Article II, Section 3 of this policy. Any sum payable by the Insurance Company as a death claim shall be paid at its Home Office in Los Angeles, California, to the beneficiary entitled thereto in accordance with the provisions ); of this policy. This policy is issued in consideration of the application of the Policyholder, a copy of which is attached to and made a part of this Policy, and of the pay- ; ment by the Employer of premiums as herein provided. The period beginning on the effective date of this policy and ending on December ', 31, 1955, shall be considered the first policy year. Each policy year thereafter shall commence on the first day of each January and end on the thirty-first day of the following December. A policy month shall commence on the first day of the calendar month. ►' The benefits and provisions on the subsequent pages of this policy are part of this policy as fully as if recited over the signature hereto. IN WITNESS WHEREOF, PACIFIC MUTUAL LIFE INSURANCE COMPANY has caused this policy to be executed at Los Angeles, California, as of the first day of April, 1955, its effective date. *<;e Secretary President > > Registrar > Group Life Insurance Policy Contributory > GR-202- 6 Tell El t zn ua ,,arc„..,,,I�a t L id s;lw.,, ARTICLE I - ELIGIBILITY AND EFFECTIVE DATES OF INSURANCE SECTION 1. ELIGIBILITY: All employees of the Employer are eligible for in- surance under this policy except part-time employees (but not excepting full- time employees temporarily working on a part-time basis). Persons not eligible for insurance hereunder shall not, for the purposes of this policy, be deemed to be employees. Each present and future employee shall be eligible for insurance under this policy as follows: (a) on the effective date of this policy if the employee is then employed by the Employer, otherwise (b) (1) with respect to an employee of each Employer other than Weld County General Hospital, immediately upon comple- tion of one calendar month of full-time employment with the Employer, or (2) with respect to an employee of Weld County General Hos- pital, immediately upon completion of three calendar months of full-time employment with the Employer. SECTION 2. EYFECTIVE DATE OF AY EMPLOYEE'S TERM INSURANCE COVERAGE: The employees covered for Term Insurance shall be such of the eligible employees as make written request for insurance under this policy to the Employer and agree to make the required contributions to the Employer; provided that: (a) if such request is made by an employee on or before his date of eligibility, the employee shat) become covered for Term Insurance on such date of eligibility; (b) if such request is made by an employee within thirty—one days after his date of eligibility, the employee shall become covered for Term Insurance on the date of such request; (c) if such request is made by an employee more than thirty-one days after his date of eligibility, or is made after previous termination of Term Insurance coverage because of failure to make the required contribution, the Insurance Company reserves the right to require of the employee, without expense to the Insurance Company, evidence of insurability satisfactory to the Insurance Company before he may become covered for Term Insurance. If such evidence is required and submitted, the employee shall become covered for Term Insurance on the date the Insurance Company determines the evidence to be satis- factory. In any instance in which an employee is both disabled and not working on the date he would otherwise become covered for Term Insurance, the effective date of the employee's Term Insurance coverage shall be deferred until his return to ac— tive work. SECTION 3. EFFECTIVE DATES OF PAID-UP INSURANCE: Paid-Up Insurance for an employee may be purchased only while Term Insurance coverage is in force for the employee and shall become effective as and when purchased. ARTICLE II - AMOUNT OF INSURANCE AND EMPLOYEE CONTRIBUTTCNS SECTION 1. TOTAL AMOUNT PAYABLE AT DEATH: The total amount payable at the death of an insured employee shall be equal to the sum of the amounts of Paid-Up Insurance which have been purchased for him under Section 5 of this Article and which are in force at his death, plus the amount, if any, of Term Insurance for which the employee is then covered. SECTION 2. AMOUNT OF TERN" INSURANCE: The amount of Term Insurance for each em— ployee covered for Term Insurance shall at any time be equal to the excess, if any, of the employee's Total Insurance, as determined from Section 3 of this Article, over the sum of the amounts of Paid—Up Insurance which have been purchased for the employee and which are in force. - 2 - SECTION 3. TOTAL INSURANCE FOR EMPLOYEES COVERED FOR TERM; INSURANCE: The Total Insurance which shall be in force on the life of any employee insured hereunder shall be $1,000. SECTION 4. EMPLOYEE CONTRIBUTIONS: The contributions of the individual insured employees, payable only while Term Insurance is in force, toward the payment of premiums shall be $1.30 per month per $1,000 of insurance. SECTION 5. PURCHASE OF PAID-UP INSURANCE BY EMPLOYEE CONTRIBUTIONS: Each con— tribution made by an employee in accordance with Section 4 of this Article when paid by the Employer to the Insurance Company as part of a premium shall be applied to purchase Paid-Up Insurance for such employee in an amount determined from Table I hereof on the basis of the employee's age on his birthday nearest the midpoint of the policy year in which the contribution is made. No Paid-Up Insurance shall be considered to have been purchased unless the premium therefor shall have been paid by the Employer to the Insurance Company. ARTICLE III - TERMINATION OF EMPLOYMENT SECTION 1. DEFINITION OF TERMINATION OF EMPLOYMENT: Cessation of active work with the Employer shall be deemed termination of employment for the purpose of this policy, except that if an employee is temporarily laid off or is granted a leave of absence (except a leave of absence to enter military or naval service) or is absent on account of sickness or injury, employment shall be deemed to con— tinue during such lay—off or absence, but if such lay—off or absence exceeds one year, employment shall be deemed to terminate one year after the commencement of such lay—off or absence. When an employee's absence due to sickness or injury shall exceed one year, the Employer may, on written notice to the Insurance Company within thirty—one days after the end of such year, elect that the employment of such employee shall be deemed to continue, for the purposes of this policy, until the Employer shall notify the In— surance Company in writing that such employment shall be deemed to terminate, or un— til the employee shall elect to receive the Cash Surrender Value provided in Section 5 of this Article, or until the policy shall discontinue, whichever shall first occur. During such continuance of employment, whether or not the employee continues to make contributions, the Term Insurance coverage of the employee shall remain in force and premiums therefor shall be paid by the Employer. SECTION 2. EFFECT ON TERM INSURANCE AND PAID-UP INSURANCE UPON TERMINATION OF EMPLOYMENT: Upon termination of employment of an employee, any Term Insurance cover- age of such employee shall expire automatically on the thirty-first day following such termination, and no further Paid-Up Insurance shall be purchased for him under this policy unless he shall again become covered for Term Insurance in accordance with Article I hereof. If the amount of his Paid—Up Insurance in force at the date of such termination is less than $100, such Paid—Up Insurance shall be cancelled automatically thirty—one days after termination of employment, and the Insurance Company, or the Employer on behalf of the Insurance Company, shall pay to the em- ployee the Cash Surrender Value of such Paid-Up Insurance, determined in accor- dance with Section 5 of this Article. If, however, the amount of his Paid-Up In— surance in force at date of such termination is at least $100, his Paid—Up Insurance shall remain in force, subject to his right to surrender them for a Cash Surrender Value in accordance with Section 5 of this Article. SECTION 3. PRIVILEGE OF CONVERTING TERM INSURANCE: In the event of termination of employment of an employee, such employee shall be entitled to have issued to him by the Insurance Company, without evidence of insurability, an individual policy of life insurance without disability benefits or other supplementary benefits, provided written application for the individual policy shall be made, and the first premium thereon paid to the Insurance Company, within thirty-one days after such termination, and provided further that: (1) the individual policy shall be on any one of the forms, except term insurance, that shall be selected by the employee from among the forms then customarily issued by the Insurance Company at the age and for the amount applied for; (2) the individual policy shall be in an amount equal to or, at the option of the employee, an amount less than the sum of the amount of the em- ployee's Term Insurance under this policy which ceases because of such termination plus the amount of the employee's Paid—Up Insurance at ter- mination if that is less than $100; - 3 - (3) the premiums payable under the individual policy shall be at the Insurance Company's then customary rate applicable to the form and amount of the individual policy, to the class of risk to which the employee then belongs, and to his age attained on the effective date of the individual policy; and (L1.) any individual policy issued under the terms of this Section shall take effect at the end of the thirty-one day period dur- ing which application for the individual policy may be made. 1"Jhen a policy shall be issued to a person under the conversion privilege, it shall be in exchange for all benefits under the group policy except those pro- vided in Section 4 and 5 of this Article. - 4 - SECTION 4. ISSUANCE OF PAID-UP CERTIFICATES: Upon notice from the Employer to the Insurance Company that an insured employee 's employment has terminated, the Insurance Company shall, if the amount of the employee's Paid-Up Insurance is at least X100, issue to the Employer, for delivery to the employee, a Paid-Up Certificate containing a statement of the aggregate amount of his Paid-Up Insurance which is still in force at date of termination and to whom insurance will be pay- able at the death of the employee, together with a statement of the Cash Surrender Value described in Section 5 of this Article. SECTION 5. CASH SURRENDER VALUE: At any time after termination of employment of an employee, the employee may elect to cancel such of his Paid-Up Insurance as was purchased before such termination, and in the event such election is made the Insurance Company, or the Employer on behalf of the Insurance Company, shall pay to the employee a Cash Surrender Value determined as follows: (1) if such election is made less than five years after the employee became insured under this policy, the Cash Surrender Value shall be equal to the amount of the employee's contributions which have been applied to purchase such Paid—Up Insurance; (2) if, however, such election is made five years or more after the employee became insured under this policy, the Cash Surrender Value shall be equal to the amount of the employee's contributions which have been applied to purchase such Paid—Up Insurance or the applicable amount determined from Table II, whichever amount is greater. The Insurance Company, at its discretion, may defer the payment of any Cash Surrender Value, after an employee has elected to have his Paid—Up Insurance cancelled, for a period ending not later than ninety days after the date of the employee's election, the Paid—Up Insurance to remain in force during any such deferment. If an employee's Paid—Up Insurance is cancelled before his Term Insurance has expired, the amount of his Term Insurance shall not be increased by such cancellation, anything in Section 2 of Article II to the contrary not- withstanding. ARTICLE IV - =CT OF CEASING TO MAKE CONTRIBUTIONS BEFORE TERMINATION OF EMPLOYMENT SECTION 1. DURING ABSENCE ON ACCOUNT OF LAY-OFF OR LEAVE OF ABSENCE: If an employee ceases to make contributions while absent on account of temporary lay- off or leave of absence, his Term Insurance coverage shall expire automatically on the thirty-first day following the end of the period for which contributions have been made unless in the meantime he returns to work for the Employer and resumes contributions. In the event that an employee's Term Insurance coverage has expired under the terms of this Section, he shall again become covered for Term Insurance upon return to active work with the Employer, provided he returns before employment is deemed to have terminated and resumes contributions within thirty-one days after such return to work; otherwise he shall again becoae covered for Term In- surance only in accordance with Section 2 of Article I hereof. SECTION 2. OTHER CASES BEFORE TERMINATION OF EMPLOYMENT: In any other case when an employee ceases to make contributions before termination of employment, except while the employee is absent from work on account of sickness or injury, his Tenn Insurance coverage shall expire automatically at the end of the period for which contributions have been made, aid he shall again become covered for Term Insurance only in accordance with Article I hereof. ARTICLE V — COMPUTATION AND PAYMENT OF PREMIUMS SECTION 1. PREMIUMS FOE PAID-UP INSURANCE PURCHASED BY EMPLOYEE CONTRI- BUTIONS: At the beginning of each period specified in accordance with Section 2 of this Article, the Employer shall pay to the Insurance Company a premium in an amount equal to the total contributions payable by insured employees during such period. - 5 - SECTION 2. PREMIUMS FOR TERM INSURANCE COVERAGE: The premium rates for Term Insurance coverage shall be those in Table III. On April 1, 1955, the Employer shall pay to the Insurance Company the premium which the Insurance Company estimates will be required for Term Insurance cover- age during the period beginning on April 1, 1955, and ending on July 30, 1955. At the beginning of each succeeding six-month period of each policy year during the continuance of this policy commencing on July 1, 1955, each individual Employer other than Weld County General Hospital shall pay to the Insurance Company the premium which the Insurance Company estimates will be required for Term Insurance coverage during the six-month period then beginning. At the beginning of each policy month during the continuance of this policy commencing on July 1, 1955, Weld County General_ Hospital shall pay to the Insurance Company the premium which the Insurance Company estimates will be required for Term Insurance coverage during the policy month then beginning. At the end of each policy year the average amount of Term Insurance coverage in force during such year for employees at each age shall be determined and the correct premium for such year shall be computed from such averages. The difference between the estimated premium paid and the correct premium for such year shall be computed from such averages. The difference between the estimated premium paid and the cor- rect premium for such policy- year shall be payable to the Employer by the Insurance Company or to the Insurance Company by the Employer, as the case may be, upon notice of its amount from the Insurance Company to the Employer. SECTION 3. PAYMENT OF PREMIUMS AND GRACE PERIOD: This policy is issued in con- sideration of the payment by the Employer to the Insurance Company at its Home Office of the premiums provided for in this Article V. Thirty-one days of grace without interest charge will be allowed for the payment of every premium after the first. ARTICLE VI - DISCONTINUANCE OF POLICY SECTION 1. CAUSE AND EFFECTIVE DATE OF DISCONTINUANCE: If any premium is not paid before the expiration of the grace period allowed for its payment, this policy shall automatically discontinue with respect to all employees at the expiration of the grace period, except that if the Employer shall have given the Insurance Com- pany written notice in advance of an earlier date of discontinuance during such grace period, this policy shall discontinue with respect to all employees as of such earlier date. The Employer shall be liable to the Insurance Company for the premium for Term Insurance coverage for the time such coverage was in force during the grace period. If any premium is not paid before the end of the grace period allowed for its payment, the Employer may tender such premium to the Insurance Company at its Home Office together with interest thereon at the rate of 5% per annum from its due date to the date of tender, provided it is tendered not later than thirty-one days after the end of the grace period allowed for its payment. With respect to each such tender, the Insurance Company shall have the absolute right, in its own discretion, either to accept or refuse to accept such tender. If such tender is accepted, no discontinuance of this policy shall be caused by the non-payment of the premium within the grace period. The Insurance Company reserves the right to discontinue this policy at the end of any policy month when (a) there are fewer than fifty employees contributing under this policy, or (b) less than seventy-five per cent of the total number of employees who are then actively working for the Employer and eligible for insurance under this policy are contributing under this policy; provided that the Insurance Company shall give the Employer at least ninety-days written notice of its intent to discontinue. SECTION 2. EFFECT OF DISCONTINUANCE: Upon discontinuance of this policy with respect to any employee, any Term Insurance coverage of such employee shall automa- tically expire on the date of discontinuance, and no further Paid-Up Insurance shall be purchased for him under this policy. If the amount of his Paid-Up Insurance in force at date of discontinuance is less than 3100, such Paid-Up Insurance shall be cancelled automatically at date of discontinuance, and the Insurance Company shall - 6 - pay to the employee the Cash Surrender Value of such Paid-Up Insurance, determined in accordance with Article III, Section 5 hereof. If, however, the amount of his Paid—Up Insurance in force at date of discontinuance is at least $100, his Paid—Up Insurance shall remain in force, subject to his right to surrender them at or after termination of employment for a Cash Surrender Value in accordance with Article III, Section 5 hereof. Each employee who has been continuously covered for Term Insurance at date of discontinuance of this policy for five years or more immediately preceding the date of discontinuance shall be entitled to the conversion privilege in Article III, Section 3 hereof as though employment had terminated on the date of discontinuance; except that the amount of insurance to be converted shall not exceed the amount per— mitted for such termination on such date less any amount of life insurance for which the employee may be or may become eligible under any group policy issued by the In- surance Company or any other insurer within thirty-one days after the date of discon- tinuance, nor shall it exceed $1,000. Anything in this Section to the contrary not— withstanding, the amount of insurance coverage which any employee is entitled to con— vert by reason of this paragraph shall remain in force under this policy for thirty— one days after the date of discontinuance. ARTICLE VII - BENEFICIARY AND OPTIONAL METHODS OF SETTLEMENT SECTION 1. BENEFICIARY: The amount payable by reason of the death of an employee shall be paid to the beneficiary designated by the employee. An employee, whether or not employment shall have terminated, may designate a beneficiary or change his desig— nation of beneficiary from time to time by written request filed at the Home Office of the Insurance Company. Such designation or change shall take effect as of the date of execution of such request, whether or not the employee be living at the time of such filing, but without prejudice to the Insurance Company on account of any payments made by it before receipt of such request at its Home Office. Except as may be otherwise specifically provided by the employee, (1) if any designated beneficiary predeceases the employee, the share which such beneficiary would have received if surviving the employee shall be payable equally to the remaining desig- nated beneficiaries, if any, who survive the employee; and (2) if no designated beneficiary survives the employee, payment shall be made to the employee's widow or widower if surviving the employee; if not surviving the employee, in equal shares of the employee's children who survive the employee; if none survives the employee, to the employee's parents, equally or to the survivor; if neither survives the employee, in equal shares to the employee's brothers and sisters who survive the employee; or if none survives the em— ployee, to the employee's executors or administrators. In any case, however, the Insurance Company may deduct from the amount payable in accordance with either or both of the two preceding paragraphs an amount not to exceed $250 to be applied by it for funeral and other expenses incident to the employee's last illness and death, but only when and to the extent this is desirable and equitable in its judgment. SECTION 2. METHOD OF SETTLEMENT: The insurance, or the Cash Surrender Value of any cancelled Paid—Up Insurance, shall be payable in one sum. ARTICLE VIII - GENERAL PROVISIONS SECTION 1. CERTIFICATES: The Insurance Company shall issue to the Employer, for delivery to each insured employee, a certificate setting forth a statement as to the insurance coverage to which the employee is entitled and to whom the benefits are pay— able, together with a statement of the conversion privilege described in Article III, Section 3 hereof and in Article VI, Section 2 hereof. SECTION 2. POLICY NON-PARTICIPATING: This policy shall not be entitled to share in the surplus earnings of the Insurance Company. - 7 - SECTION 3. EXPERIENCE RATING PLAN: At the end of each policy year, this policy shall be subject to experience rating in accordance with the Insurance Company's experience rating plan then in use, which experience rating plan shall take into account the reserves specified in Section 4 of this Article and such additional re— serves as the Insurance Company shall determine to be necessary or advisable. The Insurance Company shall determine, upon an actuarial basis deemed appropriate by it, whether any part of any experience rating credit applicable to this policy is derived from Paid-Up Insurance, and any such part shall be applied to increase pro- portionately the amounts of Paid-Up Insurance purchased by employee contributions during the next succeeding policy year. Any part of such experience rating credit not so determined to be derived from Paid-Up Insurance shall be applied to reduce the premium for Term Insurance coverage during the next succeeding policy year, any such decrease to be made retroactive for one year and a consequent refund to be paid to the Employer. SECTION 4. RESERVES: The reserves for which funds will be held under this policy shall be computed on the following basis: (a) as to the Paid-Up Insurance, on the basis of 2 interest per annum and the Commissioners 1941 Standard Ordinary Mortality Table, (b) as to the Term Insurance, on the basis of 3% interest per annum and the Commissioners 1911 Standard Ordinary Mortality Table; provided, however, that the reserves shall not be less than the maximum reserves required by the laws of the state in which this policy is issued. SECTION 5. ASSIGNNENT: Neither the employees nor their beneficiaries may assign the insurance or other benefits under this policy. SECTION 6. CLAIMS OF CREDITORS: The insurance and other benefits under this policy shall be exempt front the claims of creditors of the employees and from the claims of creditors of the employee's beneficiaries. If the terms of this Section are contrary to the laws governing in a particular set of circumstances, then, as to that set of circumstances, the insurance and other benefits shall be exempt to the maximum extent permitted ty law. SECTION 7. DATA REQUIRED: The Employer shall furnish or: the Insurance Company's forms such information as shall be required in order that the Insurance Company shall be able to compute premiums and keep records of the employees insured, their contri- butions, and the amounts of their insurance. The determination and findings by the Employer with respect to the fact and time of commencement, duration, and termination of employment of any employee, with re- spect to the fact and time of commencement, duration, and termination of any lay-off, leave of absence, absence for military or naval service, or absence on account of sickness or injury, with respect to the amount of any employee's contributions under this policy, and with respect to the earnings or salary of any employee, shall be conclusive and binding upon all persons for the purposes of this policy. SECTION 8. MISSTATEMENT OF AGE: If the age of an employee shall be found to have been misstated, the amounts of the employee's Paid-Up Insurance shall be adjusted in the ratio which the amount shown in Table I for the correct age bears to the amount for the incorrect age, ages being computed as of the date the misstatement was found, and Term Insurance coverage shall be adjusted accordingly if in force. SECTION 9. INCONTESTABILITY: This policy shall not be contested, except for non- oaymert of premiums, after it has been in force for two years from its date of issue; and no statement made by any employee insured under this policy relating to his insur- ability shall be used in contesting the validity of the insurance with respect to which such statement was made after such insurance has been in force prior to the con- test for a period of two years during said employee's lifetime nor unless it is con- tained in a written application signed by him. - 8 - SECTION 1O. POLICY CHANGES: This policy may be changed at any time or times by written agreement between the Insurance Company and the Policy- holder, but no such change shall affect the Paid-Up Insurance purchased before the effective date of such change, nor shall it affect the Cash Surrender Value of such Paid-Up Insurance. The Insurance Company reserves the right to make changes in this policy at any time or times provided (1) no such change shall become effective less than five years after the effective date of this policy, and (2) no such change shall affect the Paid-Up Insurance purchased before the effective date of such change, nor shall it affect the Cash Surrender Values of such Paid-Up Insurance, and ( ) in each instance the Insurance Company shall give the Employer written notice of the change at least ninety days before its effective date. SECTION 11. ASSETS SEGREGATION: The Insurance Company conducts a parti- cipating life department, a non-participating life department (in which this policy is issued) and an accident and health department. The assets of the non participating life department and of the accident and health department, to the extent of the reserves required on their respective policy liabilities, and all assets of the participating life department after providing for operating and fixed charges, are held for the benefit and security of the policyholders of each department, respectively. The assets representing corporate capital and corporate surplus are further security for all policies and other liabilities of the Insurance Company. SECTION 12. ENTIRE CONTRACT: This policy, the application of the Policyholder and the individual applications of the employees insured constitute the entire contract between the parties. All statements made by the Policyholder, or by Employer, or by any of the employees shall, in the absence of fraud, be deemed representations and not warranties and no such statement shall be used in a defense to a claim hereunder unless it is contained in a written application. No agent has authority to change this policy or to waive any of its provisions. No change in this policy shall be valid unless approved by an executive officer of the Insurance Company and evidenced by endorsement hereon, or by amendment hereto signed by the Policyholder and by an execu- tive officer of the Insurance Company. - 9 - TABLE I TABLE OF AMOUNTS OF PAID-UP INSURANCE Employee's Employee's Age on Birthday Amount of Paid-Up Age on Birthday Amount of Paid-Up Nearest Midpoint Insurance Purchased Nearest Midpoint Insurance Purchased of Policy Year By a Premium of $1.00 of Policy Year By a Premium of $1.00 16 or under $3.16 51 $1.61 17 3.10 52 1.59 18 3.04 53 1.56 19 2.98 54 1.54 20 2.92 55 1.51 21 2.86 56 1.49 22 2.80 57 1.47 23 2.75 58 1.44 24 2.69 59 1.42 25 2.64 60 1.40 26 2.59 61 1.38 27 2.53 62 1.36 28 2.48 63 1.34 29 2.43 64 1.33 30 2.39 65 1.31 31 2.34 66 1.29 32 2.29 67 1.28 33 2.25 68 1.26 34 2.21 69 1.25 35 2.16 70 1.24 36 2.12 71 1.22 37 2.08 72 1.21 38 2.04 73 1.20 39 2.00 74 1.19 40 1.96 75 1.18 41 1.93 76 1.16 42 1.89 77 1.15 43 1.86 78 1.15 44 1.82 79 1.14 45 1.79 80 1.13 46 1.76 81 1.12 47 1.73 82 1.11 48 1.70 83 1.11 49 1.67 84 1.10 50 1.64 85 and over 1.09 - 10 - TABLE II TABLE OF CASH SURRENDER VALUES This table applies only when Cash Surrender Value is elected after employee has been continuously insured under this policy for at least five years. Employee's Employee's Age on Birthday Cash Surrender Value Age on Birthday Cash Surrender Value Nearest Date Per $1,000 Nearest Date Per $1,000 Cash Surrender Value bf Cash Surrender Value of is Elected Paid-Up Insurance is Elected Paid-Up Insurance 20 $314 60 $680 21 321 61 690 22 328 62 700 23 335 63 710 24 345 64 720 25 350 65 729 26 358 66 739 27 365 67 748 28 373 68 757 29 381 69 766 30 389 70 775 31 398 71 784 32 406 72 792 33 415 73 800 34 423 74 808 35 432 75 816 36 441 76 823 37 450 77 831 38 459 78 838 39 469 79 844 40 478 80 851 41 488 81 857 42 497 82 863 43 507 83 869 44 517 84 875 45 527 85 880 46 537 86 885 47 547 87 890 48 551 88 895 49 567 89 899 50 578 90 903 51 588 91 908 52 598 92 912 53 608 93 916 54 619 94 920 55 629 95 925 56 639 96 931 57 650 97 937 58 660 98 945 59 670 9J 951 - 11 - TABLE III TABLE OF PREMIUMS FOR TERM INSURANCE Employee's Employee's Age on Birthday Monthly Premium Age on Birthday Monthly Premium Nearest Midpoint Per $1,000 of Nearest Midpoint Per $1,000 of of Policy Year Term Insurance of Policy Year Term Insurance 16 or under $ .20 56 $1.78 17 .21 57 1.93 18 .21 58 2.08 19 .22 59 2.25 20 .22 60 2.44 21 .23 61 2.64 22 .24 62 2.86 23 .25 63 3.10 24 .26 64 3.36 25 .27 65 3.64 26 .28 66 3.94 27 .29 67 4.27 28 .30 68 4.63 29 .31 69 5.02 30 .33 70 5.44 31 .34 71 5.89 32 .36 72 6.39 33 .38 73 6.92 34 .40 74 7.50 35 .42 75 8.13 36 .45 76 8.80 37 .47 77 9.54 38 .50 78 10.32 39 .54 79 11.17 40 .57 80 12.09 41 .61 81 13.07 42 .65 82 14.13 43 .69 83 15.27 44 .74 84 16.49 45 .79 85 17.80 46 .85 86 19.20 47 .91 87 20.69 48 .98 88 22.28 49 1.05 89 23.97 50 1.13 90 25.76 51 1.22 91 27.66 52 1.31 92 29.67 53 1.42 93 31.78 54 1.53 94 34.01 55 1.65 95 36.32 - 12 - r- __ Application to Pacific Mutual Life Insurance Company LOS ANGELES, CALIFORNIA by Weld County, Colorado _ Employer (GIVE FULL NAME AS IT IS TO APPEAR IN GROUP POLICY) ar Court Rouen Greeley, Colorado STREET NURSER CITY ZONE STATE for a Policy or Policies of 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 General Hospital located at Greeley_ Colorado 16th St. & 17th Ave. Weld County Health Department located at Greeley. Colorado 1027 16th St. Weld County Public Welfare Department located at Greeley, Colorado 1320 8th Ave. Weld lion my T.1 hrary 'orated at Greel ey, Colorado Contrib. or Non-Contrib. ❑ Contrib. ❑ Non-Contrib. ❑ Contrib. ❑ Non-Contrib. ❑ I Insurance Paid—up Term Life Accidental Death Disability Clasdficauon Insurance and Dismemberment Principal Su Weekly Benefit SUE" All employees $1,000.00 O Non-Occ. ❑ 24-Hour ❑ DISABILITY BENEFITS Benefits commence: day accident• day sickness (Employees may) Maximum Perini Weeks 6-Weeks' Maternity Benefit: O Yes O No Max. Daily Maximum Max. ❑ EMPLOYEE: ❑ Reimbursement Benefit $ Misc.Expense $ Peri& Amp ❑ Maternity Benefits: O Included O Excluded. Maximum Maternity Benefits $ EXPENSE BENEFITS Max.Daily Maximum Max. ❑ DEPENDENT: © Reimbursement Benefits Misc.Expense$ Period days Maternity Benefits: O Included O Excluded. Maximum Maternity Benefits $ ❑ m,:pENsE SURGICAL ❑ EMPLOYEE: Maximum Benefit$ Obstetrics O Included O Excluded BENEFITS ❑ DEPENDENT: Maximum Benefit$ Obstetrics ❑ Included O Excluded (❑ Comprehensive O In Hospital O Total Disability ❑ EMPLOYEE: Maximum Per Visit:s Office,$ Hospital,$ Home ❑ MEDICAL Benefits Commence: Visit on account of accident Visit on account of sickness BENEFITS f❑ Comprehensive O In HospitalMax. Per Visit $ Office, $ Hospital, $_—Home ❑ DEPENDENT: Benefits Commence: Visit on account of accident Visit on account of sickness ❑ DIAGNOSTIC X-RAY AND O EMPLOYEE: O Scheduled O Non-scheduled Maximum$ . LABORATORY BENEFITS O DEPENDENT: O Scheduled O Non-scheduled Maximum$ - ❑ SUPPLEMENTARY ACCIDENT BENEFITS EMPLOYEE:Maximum$ nEPENDENT:Maximum$ . ❑ POLIOMYELITIS BENEFIT EMPLOYEE:Maximum$ nFPENDENT:Maximum$ . (In lieu of all other benefits for Hospital, Surgical, Medical and Diagnostic Expenses) 1. Stateanyspecialrequests Weld. County General Hospital new Rmpinyeee must be in continuous service three (B) months before they benome ^legible Ter _ insure/31n^_ - 2. The Medical Expense insurance is contributory: for Employees O yes ❑ no; for Dependents O yes O no. 3. New Employees must be in continuous service One (1 a 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? nO- ) mployees paid on the hourly basis. yes or no 4. Employees not eligibiepart time employees and seasonal employees - 5. It is requested that the Policy or Policies become effective on_Spri 1 1 , .19_56-with premiums payable anarterlYn advance., 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 coat 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• lions 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 a the Employer, regularly performing the duties of his occupation. Signed at, ! � state ofRn1 onto this n rt, of—YSret, 19_5fWeld County, Colorad%� i n - Soliciting Agent By. _ then►an el tha Ism/ Amount of Advance Payment$ Ry - GR3lB ��qq '\ !bald of County C mmtsitawl Hello