HomeMy WebLinkAboutSymetra Life Insurance Company - Amendment Number 8SYM" ETRA
RETIREMENT I BENEFITS I LIFE
Symetra Life Insurance Company Telephone: 1-800-SYMETRA or 1-800-796-3872
777 108th Avenue NE, Suite 1200
Bellevue, WA 98004-5135
Symetra Supplemental Life Group Insurance Trust
Amendment Number 8
Employer: City of Pasco
Policy Number: 01 014685 00
Effective Date: July 1, 2004
Premium Due Dates
Premium is due on the effective date and the first of each month beginning with
August 1, 2004.
Employer Anniversaries
July 1 st of each year beginning in 2005.
SCHEDULE OF INSURANCE
Effective 01-01-2022
01 014685 00
Page 1 of 5
Eligible Classes of Employees
All regular full-time employees of the employer working a minimum of 30 hours per week.
The employees are classified as follows:
Class Designation
1 Department Directors
2 Division Managers
3 All Other Eligible Employees
4 All Eligible Uniformed Employees of
the Pasco Police Officer's Association
5 Administrative, Professional and
International Union of Operating Engineers
LGC 8241 9/84 Symetra 0 is a registered service mark of Symetra Life Insurance Company.
(Continued)
Effective 01-01-2022
01 014685 00
Page 2 of 5
Service Waiting Period
For all eligible employees: The first of the month following the date of employment.
Employee Supplemental Life Insurance Contributory
Class
Benefit Amount
1, 2, 3, 4 and 5 $10,000, $25,000, $50,000 or 1 x basic annual earnings
rounded to the next lower $1,000, if not already a multiple
thereof; maximum $100,000 as selected by the employee on
the enrollment card
Proof of good health is required when the employee elects to change their benefit option
and that change results in an increased benefit amount.
The benefit is reduced to the following:
At age: Percentage of benefit amount shown:
70 65 %
75 50%
80 30 %
Waiver of Premium Continued Protection applies to this coverage.
Employee Accelerated Benefit Insurance applies to this coverage.
Employee Supplemental Accidental Death & Dismemberment Insurance Contributory
Class
Benefit Amount
1, 2, 3, 4 and 5 $10,000, $25,000, $50,000 or 1 x basic annual earnings
rounded to the next lower $1,000, if not already a multiple
thereof; maximum $100,000 as selected by the employee on
the enrollment card
Seat Belt Benefit: 100% of the Employee Supplemental
Accidental Death and Dismemberment amount for loss of life,
to a maximum of $50,000
The benefit is reduced to the following:
At age: Percentage of benefit amount shown:
70 65%
75 50%
80 30 %
LGC 8241 9/84
(Continued)
Effective 01-01-2022
01 014685 00
Page 3 of 5
Dependent Supplemental Life Insurance Contributory
Class
Benefit Amount
1, 2, 3, 4 and 5 Spouse: 50% of the Employee Supplemental Life Benefit
Amount; maximum $50,000*
** Child: $5,000
* Proof of good health is required when the employee elects to change their benefit option
and that change results in an increased benefit amount.
* At spouse's age 70, or the employee's retirement, whichever occurs first, the benefit
amount terminates.
* * "Child", as used in the Definitions section, refers to one:
who is at least 14 days old, but:
(1) who is less than age 19; or
(2) who is less than age 23 and:
(a) who has the same home address as the employee;
(b) who is not employed on a full-time basis; and
(c) who is attending college as a full-time student.
Spouse Supplemental Accidental Death & Dismemberment Insurance Contributory
Class
Benefit Amount
1, 2, 3, 4 and 5 50% of the Employee Supplemental Life Benefit Amount;
maximum $50,000**
Seat Belt Benefit: 100% of the Spouse Supplemental
Accidental Death and Dismemberment amount for loss of life,
to a maximum of $50,000
At spouse's age 70, or the employee's retirement, whichever occurs first, the benefit
amount terminates.
***Spouse Supplemental Life and Accidental Death & Dismemberment Benefit Amounts
will not be affected by the Acceleration of any portion of the Employee Supplemental
Life Benefit Amount.
A minimum participation of 15% and at least 10 lives is required in order to maintain these
coverages.
LGC 8241 9/84
(Continued)
Effective 01-01-2022
01 014685 00
Page 4 of 5
LGC 8243, Employee Provisions, "Date a Change in Employee Insurance Becomes Effective"
is amended as follows:
Date a Chanqe in Emplovee Insurance Becomes Effective
Increases in the amount of employee insurance are effective on the latest of the following
dates if the employee is actively at work on that date:
(a) the first of the month following the date of change; or
(b) the date Symetra approves the proof of good health, if required.
If the employee is not actively at work on the latest date specified above, the increase will
become effective on the date the employee returns to active work.
Decreases in the amount of employee insurance are effective on the first of the month
following the date of change.
LGC 8257, General Provisions, "Changes in Contract" is amended as follows:
This policy may be changed at any time by written agreement between Symetra and officers
of the policyholder. Changes will be valid only if approved by an officer of Symetra and
endorsed or attached to this policy. No agent has the authority to change this policy or to
waive any of its provisions. No change requires the consent of any employee or beneficiary.
LGC 8241 9/84
(Continued)
Effective 01-01-2022
01 014685 00
Page 5 of 5
The following contract pages apply:
LGC 8239
Schedule of Insurance
LGC 8240
Policy Specifications
LGC 8243
Employee Provisions - Contributory
LGC 8245
Dependent Provisions - Contributory
LGC 8246
Employee Life Insurance
LGC 8247
Waiver of Premium - Continued Protection
LGC 2338
Employee Accelerated Benefit Insurance
LGC 8248
Employee AD&D - 24 hour
LGC 8250
Dependent Life Insurance
LGC 8252
Spouse AD&D - 24 hour
LGC 8253
Definitions
LGC 8254
Claim Provisions
LGC 8255
Beneficiary and Settlement Provisions
LGC 8256
Premium Provisions
LGC 8257
General Provisions
Employer: City of Pasco
By:
Title: Human Resources Director
Date: 1 /31 /2022
SYMETRA
RETIREMENT I BENEFITS I LIFE
Symetra Life Insurance Company
Margaret Meister,
President
LGC 8241 9/84 Symetra 0 is a registered service mark of Symetra Life Insurance Company.
YM E T R SA
RETIREMENT I BENEFITS I LIFE
Symetra Life Insurance Company
777 108th Avenue NE, Suite 1200
Bellevue, WA 98004-5135
Amendment Number: 4
Group Policy Number: 01 014685 00
Policyholder: City of Pasco
Telephone: 1-800-SYMETRA or 1-800-796-3872
The policyholder and Symetra agree as follows:
Effective January 1, 2022:
The following page is hereby replaced:
LGC 8003; Schedule of Insurance.
Page: 1 of 1
The "Date a Change in Employee Insurance Becomes Effective" provision applies to this change.
Nothing contained here shall be held to alter or affect any of the terms and conditions of the policy other
than as stated.
This policy is delivered in and governed by the laws of the governing jurisdiction and, to the extent
applicable, by The Employee Retirement Income Security Act of 1974 (ERISA) and any amendments
thereto.
City of Pasco Symetra Life Insurance Company
By: By: Margaret Meister,
President
Title: Human Resources Director
Date: 1 /31 /2022
Registrar: Connie Kwong-Lam
Date: January 26, 2022
Instructions: (1) Sign and return to Symetra.
(2) Retain copy with your policy.
LGC 8041 6/95 Symetra 0 is a registered service mark of Symetra Life Insurance Company.
SCHEDULE OF INSURANCE
Effective 01-01-2022
01 014685 00
Page 1 of 2
Eligible Classes of Employees
All regular full-time employees of the policyholder working a minimum of 30 hours each
week. The employees are classified as follows:
Class Designation
1 Department Directors
2 Division Managers
3 All Other Eligible Employees
4 All Eligible Uniformed Employees of
the Pasco Police Officer's Association
5 Administrative, Professional and
International Union of Operating Engineers
Service Waiting Period
For all eligible employees: The first of the month following the date of employment.
Employee Life Insurance Non -Contributory
Class Benefit Amount
1 $100,000
2 $75,000
3 $15,000
4 $50,000
5 $50,000
The benefit is reduced to the following:
At age: Percentage of benefit amount shown:
70 65%
75 50%
80 30 %
Waiver of Premium Continued Protection applies to this coverage.
Employee Accelerated Benefit Insurance applies to this coverage.
LGC 8003 1 /80
SCHEDULE OF INSURANCE
Effective 01-01-2022
01 014685 00
Page 2 of 2
Employee Accidental Death & Dismemberment Insurance Non -Contributory
Class Benefit Amount
$100,000
2 $75,000
3 $15,000
4 $50,000
5 $50,000
The benefit is reduced to the following:
At age: Percentage of benefit amount shown:
70 65 %
75 50%
80 30 %
LGC 8003 1 /80