HomeMy WebLinkAbout760621.tiff RESOLUTION
RE: AMENDMENTS TO AGREEMENT BETWEEN WELD COUNTY AND PACIFIC
MUTUAL LIFE INSURANCE COMPANY.
WHEREAS, heretofore Weld County by Resolution did enter
into a contract with Pacific Mutual Life Insurance Company
for group insurance covering Weld County employees under the
group insurance policy and amendment thereto, to-wit:
Group Policy No. GM-8864 - Amendment No. 6. , and
WHEREAS, the Board of County Commissioners, Weld County,
Colorado, believes it to be in the best interest of the
County to accept the aforementioned amendment to the afore-
mentioned group policy as proposed, covering its said group
policy as hereinabove mentioned and on the basis recited
herein.
NOW, THEREFORE, BE IT RESOLVED, by the Board of County
Commissioners, Weld County, Colorado, that the hereinabove
mentioned amendment No. 6 submitted by Pacific Mutual Life
Insurance Company amending Group Policy No. GM-8864, a copy
of which is attached hereto and made a part hereof by ref-
erence, be, and it hereby is approved.
BE IT FURTHER RESOLVED, that the Board be and it hereby
is authorized to execute amendment No. 6 to the aforementioned
group policy, to-wit: GM-8864 as submitted, and to make the
same effective forthwith.
The above and foregoing Resolution was, on motion duly
made and and seconded, adopted by the following vote on the
26th day of July, A.D. , 1976.
BOARD OF COUNTY COMMISSIONERS
WEL OUNTY, COLORADO
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ATTEST f- - ' / /
Weld County Clerk and Recorder
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- 1 Qountry ,ttorney
' AMENDMENT NO. 6 POLICYHOLDER'S COPY
Attached to and part of 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. 6 effective June 1, 1976".
COLUMN I - PAGES DELETED COLUMN II - PAGES INSERTED
11B-3-c(2) 11B-3-c(2)
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 MUTUA/L/LIFE INSURANCE COMPANY
2
Signature of Officer President
1,12tAA Ofita
TITLE Chw i rma p T
Board of County Commissioners Secretary
Weld County, Colorado //A�/ -- _ y/�� f
DATE July 26, 1976 ATTEST '� "'�i("""""7�` —Y'""Q""`.,4"4.-4,..„
Registrar /
DATE / 3 i/ 7U
GR-4827-B
•
COMPREHENSIVE MAJOR MEDICAL EXPENSE BENEFITS(Continued)
SCHEDULE OF BENEFITS
Classifications 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 accommodation other than an intensive care unit the hospital's charge for semi-
private accommodations not to
exceed $68
(b) an(includiing care unit 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
AU 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. 6 EFFECTIVE JUNE 1, 1976 Page IIB-3-c(2)
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