Resolution No. 5819
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RESOLUTION NO. 5819
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A RESOLUTION OF THE CITY COUNCIL OF THE
CITY OF VERNON APPROVING AND AUTHORIZING
THE EXECUTION OF A MASTER STOP LOSS POLICY
(GUG-2R03) BY AND BETWEEN THE CITY OF
VERNON AND UNITED OF OMAHA LIFE INSURANCE
COMPANY (OMAHA)
WHEREAS, the city Council of the City of Vernon adopted
Resolution No. 5813 on August 21, 1990, declaring its intention
to renew the Master stop Loss Policy and Administrative Services
Contract with Omaha; and
WHEREAS, the Master stop Loss Policy approved by the
City Council of the city of Vernon on November 7, 1989, by
Resolution No. 5687 terminated on August 31, 1990;
WHEREAS, the City of Vernon and Omaha desire to enter
into a Master stop Loss Policy to provide insurance coverage
under the city's self-insured health plan that pays for
hospital, surgical and medical expenses above certain limits for
the period of september 1, 1990 through August 31, 1991.
NOW, THEREFORE, BE IT RESOLVED BY THE CITY COUNCIL OF
THE CITY OF VERNON AS FOLLOWS:
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SECTION 1: The city Council of the City of Vernon
hereby finds and determines that the recitals contained
hereinabove are true and correct.
SECTION 2: The City council of the City of Vernon
hereby approves the Master stop Loss pOlicy, effective September
1, 1990, a copy of which has been presented to the city Council
concurrently with this resolution and the City council hereby
orders said Master stop Loss Policy to be received and filed by
the City Clerk.
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SECTION 3: The city Council of the City of Vernon
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hereby authorizes the Mayor and the city Clerk to execute said
Master stop Loss Policy for, and on behalf of, the City of
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Vernon.
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certify to the passage of this resolution and thereupon and
SECTION 4: The City Clerk of the city of Vernon shall
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thereafter the same shall be in full force and effect.
AT;:!
BRUCE V.
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APPROVED AND ADOPTED this 4th day of september, 1990.
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MALKENH RST, City Clerk
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1 STATE OF CALIFORNIA )
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2 COUNTY OF LOS ANGELES )
3 I, BRUCE V. MALKENHORST, City Clerk of the City of
4 Vernon, do hereby certify that the foregoing Resolution, being
5 Resolution No. 5819, was duly adopted by the City Council of the
6 City of Vernon at a regular meeting of the City Council duly
7 held on Tuesday, September 4. 1990. and thereafter duly signed
8 by the Mayor of the City of Vernon.
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BRUCE V. MALKENHORST,City Clerk
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United of Omaha Life Insurance Company
Home Office: Mutual of Omaha Plaza, Omaha. Nebraska 68175
A Stock Company
(herein called United)
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has issued this Policy to
CITY OF VERNON
(herein called Policyholder)
This policy is issued in consideration of the terms, conditions and limitations of this policy.
This policy is effective September I, 1990, at 12:01 a.m., Standard Time, at the main office of the
Policyholder.
United agrees to reimburse the Policyholder for excess Plan Payments made for the benefit of
employees and their eligible dependents, in accord with the terms, conditions and limitations of
this policy.
This policy is issued in and is subject to California law.
UNITED OF OMAHA LIFE INSURANCE COMPANY
-<fLv~
President
tt
Secretary
UnitedC\
o/Omilhil~
A MfIIIIiII of 0..- Conrp;uuJ
Form 5654GM-U-EZ
No.5
GROUP POLICY NO. GUG-2R03
(herein called Policy)
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HEALTH CONVERSION
GUG-2R03
Stop-Loss Insurance
Definition
Conversion Coverage means individual or family hospital, surgical and medical insurance issued
without evidence of good health.
Available to Employees
Conv~rsion coverage is available to an employee whose Plan coverage ends because his or her
eligibility ends~ except conversion coverage is not available when:
(a) the Plan ends, the employer withdraws from the Plan or the policy ends~
(b) the employee has similar individual or group coverage~
(c) the employee is eligible for or has Medicare coverage~ or
Cd) the employee has been covered under the Plan less than three months immediately
before Plan coverage ends.
Available to Dependents
Conversion coverage is available to a dependent whose Plan coverage ends because:
(a) the employee's Plan coverage ends~ .
(b) of death, divorce or annulment~ or
(c) a child reaches the limiting age in the Plan~
except conversion coverage is not available when:
(a) the Plan ends, the employer withdraws from the Plan or the policy ends~
(b) a dependent has similar individual or group coverage~
(c) a dependent is eligible for or has Medicare coverage~ or
(d) the employee has been insured under the Plan less than three months immediately
before the dependent's Plan coverage ends.
Option to Obtain Conversion Coverage
If a completed application and the first premium payment is sent to us within 31 days from when
Plan coverage ends, * conversion coverage will be issued in accord with:
(a) our rules; and
(b) the conversion law in effect when application is made.
*NOTE: Application must be made when Plan coverage ends; not when any extended benefits
under the Plan end.
Application may be made:
Form 6074GI-U-EZ
PREMIUM RIDER
This rider is made a part of Group Policy GUG-2R03.
This rider is effective September 1, 1990.
The premiums for the policy will be as follows.
Individual Stop Loss Insurance Premium:
Employee .............................................. $23.50 per month.
Aggregate Stop Loss Insurance Premium:
Employee ............................................... $1.72 per month.
Dated: August 22, 1990
UNITED OF OMAHA LIFE INSURANCE COMPANY
~ ~~:rY
Form 105GR-EZ
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If the sum of all Plan Payments for all persons during the Accumulation Period, excluding
those Plan Payments reimbursable under any Individual Stop-Loss Limit, exceeds any
Aggregate Stop-Loss Limit, United will reimburse 100% of this excess to the Policyholder.
3. MAXIMUM REIMBURSEMENT
United's liability under any Individual Stop-Loss Limit provlSlon of this policy will not
exceed $1,000,000
United's liability under any Aggregate Stop-Loss Limit provIsIon of this policy will not
exceed $ Unlimited.
GENERAL PROVISIONS
1. PAYMENT OF PREMIUMS
The first premium Due Date is September 1, 1990 for the Period of Coverage beginning
September 1, 1990 and ending September 30, 1990.
Premiums for each subsequent Period of Coverage are due by the corresponding Due Date:
Period of Coverage
October 1 through October 31
November 1 through November 30
December 1 through December 31
January 1 through January 31
February 1 through February 28
March 1 through March 31
April 1 through April 30
May 1 through May 31
June 1 through June 30
July 1 through July 31
August 1 through August 31
Due Date
October 1
November 1
December 1
January 1
February 1
March 1
April 1
May 1
June 1
July 1
August 1
The premium payable for each Period of Coverage is the sum of the individual premiums for
each person insured, including any dependents' premiums. Individual premiums are based
on an insured person's classification when a Coverage Period begins.
Form 5654GM-U-EZ
No.5
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7. INFORMATION TO BE FURNISHED BY THE POLICYHOLDER/PRIVACY
The Policyholder is responsible for keeping confidential Plan records. These records are to
be kept in a way which will assure the privacy of medical and other personal information.
The records must show:
(a) persons covered by classification, and any persons eligible but not covered~
(b) the amount of money contributed by the Policyholder toward premiums~ and
(c) any other Plan information which United may reasonably request.
These records and any other Plan information which the Policyholder has or reviews will be
used by the Policyholder only for the purpose of Plan administl:ation.
The Policyholder will furnish, as United requires, any Plan information on United's forms
which are needed for policy administration.
The Policyholder's books and records which may have a bearing on the coverage under this
policy shall be open to United for inspection. The books and records may be inspected at any
reasonable time while this policy is in force and for one year afterwards.
8. POLICY CHANGES
No change in this poli.cy is valid unless approved in writing by an officer of United. No agent
has authority to change this policy or to waive any of its provisions.
The Policyholder accepts the provisions of this policy by its signature.
City of Vernon
For
Policyholder
By--r~4~~~~~~ ..
Attest: /~ _ ~ v "~~
Bruce V. Ma enhorst Title C1ty Clerk
United of Omilhil Life Insurilnce Compilng
Countersigned by:
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Licensed Resident Agent a
Form 5654GM-U-EZ
No.5