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Home My WebLink About990191.tiff AGREEMENT FOR CONTINUATION OF HEALTH INSURANCE FOR FORMER WELD COUNTY EMPLOYEE OR ELECTED OFFICIAL WHO IS NOW DRAWING BENEFITS FROM THE WELDCO/UNTY RETIREMENT PLAN THIS AGREEMENT is entered into this 'r/ day of ;)a t�ra ,t� / ';'r; by and between (; ;yrs74r_,ci7 L. /AHrZen , whose address is J 7Fc ,- <1;2K-wit hereinafter referred to as "Retiree," and the Board of County Commissioners of Weld County, Colorado, whose address is P.O. Box 758, 915 10th Steet, Greeley, CO 80632, hereinafter referred to as "Board." WITNESSETH: WHEREAS, Retiree retired from employment with Weld County on or after December 16, 199E, after at least 10 years of service; or was an elected official of Weld County, Colorado, for at least one full four-year term; has attained the age of 55 years; and is now drawing benefits from the Weld County Retirement Plan, and WHEREAS, on the date of his or her retirement or end of office, Retiree and\or his dependents,was(were)enrolled and in good standing with Weld County's health insurance program, and WHEREAS, Retiree wishes to continue his or her health insurance and\or his or her dependents' health insurance through Weld County's health insurance program pursuant to the terms and conditions set forth in this Agreement. NOW,THEREFORE,in consideration of the mutual promises and covenants set forth herein, and in consideration of Retiree's service to Weld County for the past ten years, or as an elected official for at least one full four-year term, the parties hereto agree as follows: 1. CONTINUED HEALTH INSURANCE FOR RETIREE: Conditioned upon Retiree's prompt payment of the monthly health insurance premium as detailed in Paragraph 4.. below, and non-cancellation of the Retiree's health insurance, Retiree shall be eligible for continued health insurance through Weld County's health insurance provider until Retiree attains the Normal Retirement Age for Social Security ("NRA"), or becomes eligible for health insurance coverage with another employer, or becomes eligible for Medicaid or Medicare coverage before attaining the NRA. Such continued health insurance shall be the same as that offered to regular, full-time,current employees of Weld County, through the same health insurance provider. Retiree acknowledges and agrees that the health insurance provider who is providing such continued health insurance may change without Retiree's consent. 2. CONTINUED HEALTH INSURANCE FOR RETIREE'S DEPENDENT(S): On the date of Retiree's retirement, he or she had dependant(s)(hereinafter"Dependent(s)") enrolled in and in good standing with Weld County's health insurance program. Conditioned upon Page 1 of 4 Pages (;C: W , Ppl. 990191 Ca��u�f LL��.<dti Pe cx i Co c. {nc/OQ Retiree's prompt payment of the monthly health insurance premium on behalf of Dependent(s), as detailed in Paragraph 4., below, and non-cancellation of the Dependant(s)' health insurance, Dependent(s) shall be eligible for continued health insurance through Weld County's health insurance provider, until either of the following: I) Retiree attains the NRA, or becomes eligible for health insurance coverage with another employer,or becomes eligible for Medicaid or Medicare coverage before attaining the NRA, or becomes otherwise ineligible; or 2) Dependent(s) lose(s) his or her (their) eligibility for continued health insurance by attaining the NRA, or becoming eligible for health insurance coverage with another employer, or becoming eligible for Medicaid or Medicare coverage before attaining the NRA. Such continued health insurance shall be the same as that offered to regular, full- time, current employees of Weld County, through the same health insurance provider. Retiree, on behalf of his or her dependent(s), acknowledges and agrees that the health insurance provider who is providing such continued health insurance may change without Retiree's and\or his or her dependent(s)' consent. 3. DETERMINATION OF ELIGIBILITY: The determination of eligibility for the Retiree's and\or his or her Dependent(s) in the continued health insurance shall be by the Weld County Director of Personnel,with any appeal to the insurance carrier, who shall have final authority to make such determination. 4. COBRA RIGHTS: Retiree and\or his or her dependent(s) shall have the same rights under the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) as do regular, full- time,current employees of Weld County eligible for and participating in the County's regular health insurance program. 5. CONTINUED HEALTH INSURANCE PREMIUM: The premium Retiree shall pay, for his own continued health insurance coverage and\or for continued health insurance coverage for his or her dependant(s), shall be the same as that paid on behalf of regular, full-time, current employees of Weld County. The County contribution paid for the Retiree's and\or his or her Dependent(s) shall also be the same as that paid on behalf of regular, full-time, current employees of Weld County. Retiree, on his own behalf and on behalf of his Dependent(s), acknowledges and agrees that premium rates may change without Retiree's and\or his or her dependent(s)' consent. 6. RETIREE WORKING FOR WELD COUNTY IN LESS THAN FULL-TIME POSITION: The fact that Retiree may continue to work for Weld County in less than a full-time position does not make Retiree and\or his or her Dependent(s) ineligible for continued health insurance, if the requisites of eligibility set forth above are otherwise met. • 7. TERM: The term of this Agreement is from December 16, 1998, or the Retiree's date of retirement, to and until such time as Retiree and\or his or her Dependent(s) are no longer eligible for continued health insurance as determined by the terms of this Agreement. Page 2 of 4 Pages 990i9 8. NATURE OF AND AUTHORITY FOR CONTINUED HEALTH INSURANCE: The continued health insurance contemplated by this Agreement is being offered to Retiree and\or his or her Dependent(s) as a fully funded benefit in consideration of Retiree's service to Weld County over the course of the previous 10 years, or as an elected official for at least one full four-year term. The continued health insurance is not a part of or paid from the Weld County Retirement Plan, nor is it a defined benefit retirement plan pursuant to the provisions of Section 401(a) of the I.R.S. Code. 9. SEVERABILITY: If any term or provision of this Agreement, or the application thereof to any person or circumstances shall, to any extent, be held invalid or unenforceable, the remainder of this Agreement, or the application of such terms or provisions, to a person or circumstances other than those as to which it is held invalid or unenforceable, shall not be affected, and every other term and provision of this Agreement shall be deemed valid and enforceable to the extent permitted by law. 10. NO WAIVER OF IMMUNITY: No portion of this Agreement shall be deemed to constitute a waiver of any immunities the parties or their officers or employees may possess, nor shall any portion of this Agreement be deemed to have created a duty of care which did not previously exist with respect to any person not a party to this Agreement . 11. NO THIRD PARTY BENEFICIARY ENFORCEMENT: It is expressly understood and agreed that the enforcement of the terms and conditions of this Agreement, and all rights of action relating to such enforcement, shall be strictly reserved to the undersigned parties (including the Retiree's Dependent(s)) and nothing in this Agreement shall give or allow any claim or right of action whatsoever by any other person not included in this Agreement. It is the express intention of the undersigned parties that any entity other than the undersigned parties receiving services or benefits under this Agreement shall be an incidental beneficiary only. 12. MODIFICATION AND BREACH: APPLICABLE LAW;VENUE: This Agreement contains the entire agreement and understanding between the parties hereto and supersedes any other agreements concerning the subject matter of this transaction, whether oral or written. Modifications, amendments, notations, renewals, or other alterations of or to this Agreement shall only be deemed valid or of any force or effect whatsoever if mutually agreed upon in writing by the undersigned parties. No breach of any term, provision, or clause of this Agreement shall be deemed waived or excused, unless such waiver or consent shall be in writing and signed by the party claimed to have waived or consented. Any consent by any party hereto or waiver of, a breach by any other party, either expressed or implied, shall not constitute a consent to, waiver of or excess of any other different or subsequent breach. Applicable law in any dispute between the parties hereto with respect to the subject matter herein shall be the law of the State of Colorado. Venue for any litigation between the parties shall be in Weld County District Court. Page 3 of 4 Pages 99nigi THE PA RTIES HERETO HAVE SET THEIR SIGNATURES HERETO THE DATE ENTERED aVE. / ATTEST: 1 `�, BOARD OF COUNTY COMMISSIONERS CLERK TO THE BOA OF i " OF WELD COUNTY, COLORADO COUNTY COMMISSI IA r : p BY: w "� BY: — Deputy Clerk to the _ 'd' .y.' , Chair NAME OF DEPENDENT(S): RETIREE: (Print Name of Dependent(s)) Signature of Retiree eA A,S?Mt'Ct7 a /74-r- S- a J_. (Print Name of Retiree) Page 4 of 4 Pages 99v / 9 f Ely (. 4 : BlueCrossBlueShield Fy III W of Colorado* Mir)— gr 0 - Rocky Mountain lye , • Colorado �'( nsurance Company , BlueAdvantage Enrollment.Application I Change Form CHAISER C REASON POCMPLS'TION OP APPLICATION / ❑NewApptlatlgn O Beet/dory Chimp ❑%Stale 0 Terrine* 0 AdereeerTeleglicre Chimp Cl Nero Change,Parlous Name ❑PCP Chage )j ❑Rmae Farr*Mntns DAddFamlyMenbrt Riseez... , Q+OWfe9 NET— LSa1r/Chage Jp Other,:f . -r'trtl INDICATE HEALTH COVERAGE SELECTED SOCIAL SECURITY NUMBER' I •S l)tudo rel to proves Mil nix- _$I r� HMOPOINT OF SERVICE tL` �".� .I —�f 1 S,) —I` �/' I/ 4r armenmalign,etenhaumber wigledrlda ° F ❑ ❑OTHER: ;— ` vayrinrreeehb. j pf NAME(Lestt,First,Midde Instal) / ISEX O,M AF I 1�d yf i is,—7 ( /; '/ Yi r„" 1f a ,.r1'V' t e l ./d£ 7- ADDRESS(Met) // n ` dA iSTAATTTE/ ZIP CODE /� HOME TELEPHONE p'S a! "),241.:I-' i` l^,F4i it: l(fl A't PFPA IC;^J i (a 4� 54n(' -g/ 9A^ )"'.% EMPLOYER NAME GROUP.NUMBER BUSINESS TELEPHONE BIRTHDATF,(Mo..Day.Yr.) �/61° // i / are,1V y ( ) 17 Ii 'S .. i FULL- ME EMPLri OYMENT7NE,bay,Yr.( ' HEALTH COVERAGE DESIl1ED DENTAL COVERAGE DESIRED I P ., 4I e ❑Enpcaea Spnaiss ❑Employee/Xt.') ❑Fwliy ❑Single ❑Envloyeea Spouse ❑Enlpty's&cta n) ❑Fan*y I 0 Decke(Wo, ammales wenerlam) ❑Dedire(yw'met completes wanerbm) [ POSITION TITLE HOURS WORKEDMEEK EARNINGS 0 HOURLY 0 SEMIMONTHLY IF YOU AND YOUR SPOUSE ARE USING DIFFERENT LAST NAMES, ..� 0 WEEKLY 0 MONTHLY CHECK APPLICABLE BOX(NOTE IF COMMON LAW SUPPLY AFFIDAVIT) '. U S 0 BIWEEKLY 0 ANNUALLY 0 Cgmman Law Marriage 0 Wife RWinlnp Maiden/Professional Name ,De ymarindntrh. ofyoflitAyh4tsaWfaat*ipeterMM.thsplay'Mr d`M+rape!L rNO CI:YES II`YES'pive 'Sareernamt _ _ ( I certify that the below-named children are financially dent on me )r deoendent_because of a court order. f- UST ALL ELIGIBLE DEPENDENTS INCLUDII4O SPOUSE YOU WISH TO COVER (If additional space is required,attach Separate sheet.) NAME (Last,First,M.I.) - RELATIONSHIP Mor F BIRTHDATE MUST COMPUTE FOR MMG a POINT OF SERVICE COVERAGE (Mo..Day.Yr.) PRIMARY CARE PROVIDER(FIRST a LAST NAME) CURRENT PATIENT AI LAY +- l °A14"an 1_/ Seir ( tr'/e7/'it: ° Ytrr,l' I YES° NO° 1 YES5 NO ,( YES0 NO0 #.. ) '.) f.. 10' YES° NOS 1 Complete this section R you are enrolling In a Blue Close Blue Shield of Colorado Health Plan such as Custom Plus,Prime,etc.: An individual may qualify for a waiver of the preexl ng waiting period as stated on the back,If the individual has had other health coverage within the last 90 days. L ' Hays you had a health plan In the last 90 days? YES ❑ N f, If yes,attach a copy of your Certificate of Covert if available,, other evidence pf coverage.If no,the Individual will be subject to a pre-existing wetting period of up to 18 months, unless the individual is applying for Coverage within 30 days of el ibility. „ -JIFMCARE COVERAGE INFORMATION—ARF YOU Vol IR SPOT(SE ANY DEPENDFNTCHILDREN COVERED UNDER MEDICATE' IF°YES."COMPLETE.AU; PART A PART B IF YOU ARE IRIYR AGE 85, MEDICARE t NAME EFF.DATE EFF.DATE GIVE REASON FOR DISABILITY CLAIM NUMBER Ft ) , . f' _ d COMPI.EE FOR ROCKY MOUNTAIN UFE COVERAGE ONLY 1 COVERAGES YOU ARE APPLYING FORSI ApptlaNe) 0 Lib end ADM i ❑Dependent UN 0 ShalTam Dleab.ey ❑Long Term Disseyty ❑Supplemental Life Amount PRIMARYI3EPEFIfiIARV NAME(FNM,'Mldde7nNd;Laot)` . . _.. .. .•., .- .:."^. : ...'.. . : RBl.ATICk7StaP - I - I SECONDARY BENEFICIARY(First.Mktle Initial,last) RELATIONSHIP f. See reverse side of Ns torn ter additional o provisions.I admoMedge that l have read the front es well as the midis,side cite ap on and tern that I urea to all matters Coveted twain EMPLOYEE _ /J ' DATE �` SIGNATURE X ��ah,1. '4'..A`A . �/(t. a�/4�/e�"�'`/- ,74 lye �E��E,��L.��C LAW t p is ALL �f�x/�j�QE� i T.kiddy Newt main b M'Yrntl sill ISO errOcNea orbit ' OLORADO INSURANCE LAW REQUIRES ALL CAa RtRS ,. IN THE SMALL GROUP MAR TO ISSUE ANY HEALTH BENEFIT PLAN IT MARKETS IN COLORA��DgqOTTO EMPLO OF 1 EES PICL DING A BASIC OR STAN- E� SMALL ®,, LL, M FIT PLAN LOVER THE HEALTH STATusOF THE INDDU- ALS IN THE GROUP. BISS-I�_ • ' OONE CANNOT BE R UNDER A BASIC I OR STANDARD HEALTH BE .,, PLAN." � �useaiiv ., GROUP NUMBER BILLING UNIT REFERENCE NO. I CLASS EXCESS LIFE SUPPLEMENTAL LIFE LIFE YES CJ NO❑ AD&D YES❑ NO❑ yZ DEP.LIFE YES 0 NO STD YES 0 NOD LTD I YES 0 NO LTD EFF.DATE EFFECTIVE DATE CP , FORM NO.IMM4(REV.11-97) WHITEMMOC—SCBSCO t CANARY/HMS-PINK/Rocky MounbM Life Insurance Company-GOLDENROD/Group Administrator •Independent Licensees of the Blue Cross and Blue Shea Association a1RegMered marks of the Blue Cron and Blue Shea Association of Independent Blue Crossand Slue Shield Pens 990/9 / Hello