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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