HomeMy WebLinkAbout1993-05-25; City Council; Resolution 93-159.
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
RESOLUTION NO. 93-159
A RESOLUTION OF THE CITY COUNCIL OF THE CITY OF
CARLSBAD, CALIFORNIA, CONFIRMING THE AMENDMENT OF
THE CITY’S CONTRACT WITH NORTHWESTERN NATIONAL
LIFE INSURANCE COMPANY TO AN “ADMINISTRATIVE
SERVICES ONLY” PLAN.
WHEREAS, effective January 1, 1986, the City of Carlsbad
contracted with Northwestern National Life Insurance Company
(NWNL) to be the claims payor for the City’s group comprehensive
medical plan (Plan); and
WHEREAS, the above Plan was established as a “split risk
agreement” plan where the administrative fees are determined
before the Plan year begins, based on estimated claims, and include
a premium fee; and
WHEREAS, under an “Administrative Services Only” (ASO)
plan, a self-insured plan, the City does not have to pay a premium
fee, and most of the administrative fees are based on actual claims
paid; and
WHEREAS, by amending the contract with NWNL to an AS0 Plan,
the City reduces its administrative expenses for the group Health
Plan.
J/J
/II
I I1 0 0
L ll ll NOW, THEREFORE, BE IT RESOLVED by the City Council of the 1
2 City of Carlsbad, California, as follows:
3 1. That the above recitations are true and correct.
4
5
6
7
8
agreement effective April 1, 1992.
9
10
11 Exhibit 3.
2. That the City Council confirms the amendment to the
City's contract with NWNL to an Administrative Services Only
3. That the City Council authorizes the attached
amendments and riders to the contract with NWNL contained in
12 PASSED, APPROVED, AND ADOPTED at a regular meeting of the
13
14
Carlsbad City Council held on the 25th day of Mav ,
15 il 1993, by the following vote, to wit:
l6 ll AYES: Council Members Lewis, Stanton, Kulchin, Nygaard, and Fin
x? 11 NOES: None
18
19
20
21 ATTEST:
ABSENT: None
22
23 A-
24 ALETHA L. RAUTENKRANZ, City cle&
25
26
(SEAL)
27
28
L * -
0
EXHIBIT 3
Copies of Amendments and Riders to the Group Health Contract
with Northwestern National Life insurance Company.
e 0
Amendments:
a) Dated September 30, 1986; effective January 1 I 1986: amend
Plan to pay 90% benefit for certain services not available
through the Preferred Provider Organization (PPO).
b) Dated April 8, 1987; effective January 1 I 1987: amend Plan to
provide modified family deductible of $300.
c) Dated April 15, 1987; effective January 1, 1987: amend Plan tc
provide a $1 million lifetime Major Medical benefit.
d) Dated May 21, 1987; effective January 1, 1987: amend Pian to
set up Account #6 for COBRA Claims.
e) Dated January 6, 1989; effective January 1, 1989: change splii
risk pooling level from $50,000 to $75,000.
f ) Dated January 22, 1990; effective January 1, 1990: the Police
Unit is no longer covered for Health benefits through NWNL.
g) Dated March 9, 1992; effective April 1, 1992: cancels split
risk contract and replaces it with ASO/Excess Risk plan.
Riders:
a) Effective January 1, 1986; NR-07886: modifications of
provisions affecting “pre-existing conditions” and “takeover
deductible and out-of-pocket expenses.”
b) Effective January 1, 1986; NR-U7887: modifications of the
provisions affecting “employee’s insurance” and “dependents’
insurance.”
c) Dated March 31, 1989; effective January 1, 1989: policy is
nonparticipating as a result of NWNL’s conversion to a stock
life insurance company.
d) Effective July 1, 1991 ; NC-287: modifications of provisions
affecting “Basic Life Insurance” and “Supplemental Life
Insurance;” insurance will decrease to 65% on the employee’s
65th birthday.
- e 0 uc: 0
- To : Northwestern National Life Insurance Company Box 20 - Minneapolis, Minnesota 55440
Request for Amendment of Group Policy(ies)
(Prepare in Triplicate)
Please be complete and specific in your request.
R'
i I Insuran c 1 /+[cy
iL
City of Carlsbad Group Policyholder
Group Policy Nurnber(s) GH-19235-0
Effective Date for Amendrnent(s) January 1, 1986
(If possible, the effective date should be the first day of a policy month)
Request is hereby made to Northwestern National Life Insurance Company for the following revi5-i to the Group Policy (ies) indicated above:
Please amend our policy to pay PW benefit (90%) for the following, since
these services are not currently available through the PPO:
Ambulance Podiatrist Psych/Marriage Counselor
Nutritionist
Physical Therapy Dental - (W, X-Ray, Lab) ' ;, r',J*- '' - rrJ , I
Ophthalmologist (treatment of diseases only, not standard exam & lens prescri
Durable Medical Equipment Acupuncture - by an M.D. only
Prescriptions Services received by all providers outside of San Diego County are also cover€
at PPO benefits.
If both PPO hospital & physician are used, all ancillary services are covered
PPO benefits as well.
-.
(If additional space is needed, please use reverse side)
Dated 5,- , 19&. Group Policyholder city of Car1sbad
BY me --
Title -gdm* U '77
PLEASE NOTE: Northwestern National Life Insurance Company will provide amendment(s) to I plish the requested revisions, provided it deems the result to he legal, appropriate for the type of ins plan involved and acceptable based on its underwriting requirements, subject to necessary adjustn any, in premium rates. In case of problem, we will contact you promptly.
0 0
To : Northwestern National Life Insurance Company Box 20 - Minneapolis, Minnesota 55440
Ro
j
Request for Amendment of Group Policy(ies) i i Insuranc
(Prepare in Triplicate)
Please be complete and specific in your request.
U!
lr j :z k
Group Policyholder Citv of Carlsbad
Group Policy Number(s) GH-19235-0
Effective Date for Amendment(s1 January 1, 1987 (If possible, the effective date should be the first day of a policy month)
Request is hereby made to Northwestern National Life Insurance Company for the following revisic to the Group Policy( ies) indicated above:
c .. Please amend plan to provide a modified family deductible of
$300.-
(If additionahpace is needed, please use reverse side)
Dated , 19n Group Policyholde
BY
WUrJEL
PLEASE NOTE: Northwestern National Life Insurance Company will provide amendment(s) to a plish the requested revisions, provided it deems the result to be legal, appropriate for the type of insc plan involved and acceptable based on its underwriting requirements, subject to necessary adjustmc any, in premium rates. In case of problem, we will contact you promptly.
I ?HA
0 e . To : Northwestern National Life Insurance Company Box 20 - Minneapolis, Minnesota 55440
RI
I
Request for Amendment of Group Policy(ies) I 1 Insuran
(Prepare in Triplicate)
Please be complete and specific in your request. 1 15;
Group Policyholder The City of Carlsbad
Group Policy Number (s) GH-1923 5-0
Effective Date for Amendment(s) January 1, 1987 (If possible, the effective date should be the first day of a policy month)
Request is hereby made to Northwestern National Life Insurance Company for the following revis, to the Group Policy (ies) indicated above:
Please amend the plan to provide a $1,000,000 lifetime Major
Medical benefit for all covered employees.
(If additionalspace is needed, please use reverse side)
Dated April 1s 9 19Rf. Grou policyhol he Cit Of Carlsbac
B d-ce- rome N.
Title Personnel Director
PLEASE NOTE: Northwestern National Life Insurance Company will provide amendment(s) to plish the requested revisions, provided it deems the result to be legal, appropriate for the type of ins plan involved and acceptable bad on its underwriting requirements, subject to necessary adjustn any, in premium rates. In case of problem, we will contact you promptly.
I r,,, 4
0 e
To : Northwestern National Life Insurance Company Box 20 - Minneapolis, Minnesota 55440
Rc
Request for Amendnlent of Group PoIicy(ies) I 1 Insuranc
(Prepare in Triplicate)
Please be complete - ’ specific in your request.
UI I i, . I_. -
I
Group Policyholder.- of Carlsbad
Group Policy Number (s) GH-19235-0
Effective Date for Amendment(s) l/l/R7 (If possible, the effective date should be the first day of a policy month)
Request is hereby made to Northwestern National Life Insurance Company for the following revisi to the Group Policy( ies) indicated above:
Please amend plan to have Account #6 set
up for COBRA Claims .*,
(If additional.space is needed, please use reverse side)
Dated- MaY *1 , 19-. 87 Gro Carlsbad
ersonnel Director
PLEASE NOTE: Northwestern National Life Insurance Company will provide amendment(s1 to plish the :: quested revisions, provided it deems the result to be legal, appropriate for the type of in: plan involved and xceptable based on its underwriting requirements, subject to necessary adjustn any, in premium rates. In case of problem, we will contact you promptly.
..
1200 ELM AVENUE
CAALSBAD. CA 92008-1989
d @
TEL
1,6 19)
aitp af (aarlebab
PERSONNEL DEPARTMENT
January 9, 1989
CAREN FRIEDMAN
Group Field Representative Northwestern Nationial Life
18400 Von Karman Ave., Suite 730 Irvine, CA 92715
Dear Caren:
The City of Carlsbad has agreed to increase their pooling level
from $50,000 to $75,000. This will be effective January 1, 1989.
According to your figures, the rates will increase by 24.6%. In
addition, here is your copy of the amendment to the split risk
agreement.
Please call me if you need additional information.
v4 Sincerely,
MAkSHA PAYNE
Acting Person..al Director
jm
Enclosure
e @
1
MASTER AMENDMENT REQUEST FOR REVISED SPLIT RISK AGREEMENT
The City of Carlsbad
Plan sponsor
GH - 19235-0
Group Numb4
Effective * the Plan Sponsor requests Northweste: National Life Insurance Company, ("NWNL") to amend and restate its entirety the Split Risk Agreement previously made between t] parties to incorporate, among others, the following summarized changes and provisions.
1. Interest on deficits
1/1/89
Interest charged on deficits will be paid by the Plan Spons
aEd will mt be subjact to inclusion in the maxirnuT monthly reimbursement level or any other limitation.
2. Mimimum monthly claims cap
A minimum monthly claims cap will be established by NWNL at the time of renewal or amepdment underwriting. NWNL may reimburse itself for claims up to this limit regardless of other fluctuation in the determination of monthly claims
limitations.
3. Two month emPloYee/dePendent count lag
For purposes of setting the maximum monthly claims cap, the employee/dependent count will come from the second precedin
plan month.
4. Calculation of Reserves
Reserves will be calculated by multiplying 12 times the
reserve rates times the greater of the following employee/dependent counts in the' last policy year.
* Number at the beginning of &he year; * Number at the end of the year; * Average number during the year.
5. Termin8tion Wtions
At termination. a retrospective premium in the amount of th reserve will be tran8ferred to NWNL. NWNL will assume all
liability for incurred but not reported claims.
The Plan Sponsor may retain the rererves and asrume liabili for all run-off claim8 if the following condition8 are met:
* The plan sponsor pays NWNL any outstanding accumula
* An approved claims administrator handles the claims * The plan sponsor gives NWNL'an acceptable
* NWNL agrees.
deficit;
hold-harmless agreement;
e
.I
6. Claim Liability Options (Choose A or B)
'? A. Plan Sponsor to repay deficits - recovery in future months/years with remaining deficit due on termination. Monthly claims cap and deficit limitation must be greater than of ecrual to 120%. (Choose one)
'1 100% monthly claims cap / 20% deficit limitation
\3 monthly claims cap (minimum cap of 100%) /
deficit limitation
'3 B. Deficit to be recovered in future months/years only as monthly claims cap allows. Monthly claims cap, deficit limitation, and year-end payment (if any) must be greatel than or equal to 125%. (Choose one)
'3 110% monthly claims cap / 15% deficit limitation
fi 1109monthly claims cap (minimum cap of 110%) / - - 257:deficit limitation
'3 100% monthly claims'>ap / 10% year end payment / I X deficit limitation
'1 - monthly claims cap (minimum cap of 100%) / 10% yea end payment / - deficit limitation
7. Insulated deficits
For those plan sponsors in a deficit position when they increase their monthly claims caps from 100% (or 105%) to 11 or more, NWNL will continue to recover existing deficits on the First of each month subject to the deficit carry-forward limitations and the new monthly cap.
8. Dividend Offset
If the Plan Sponsor is in a deficit (either insulated or not and is entitled to a dividend on any other coverage, NWNL wi apply that dividend to the accumulated Split Risk deficit.
NWNL will promptly prepare an amended and restated Split Rie Agreement, the terms and conditions of which shall constitut the contract between the parties, for delivery to the Plan
Sponsor. By it's signature hereunder, the Plan Sponsor agre that, in the absenae of any written notification to NWNL of objections made within thirty days of ita receipt of the amended and restated Agreement, the contract as amended and
restated shall become effective on the date specified therej without further action or signature of either party.
Plan Sponsor
U
e 0 I
To: Horthwatrin National LfCa Iasurmcr Company / BO% 2fl - Hinzr~~lh, IUUlrrOt4 3W0
\ (k8pua ia Trip1ic.t.)
Roqu-t tot -t of Qrorrp CoUcJ(iu)
PhUm bo cmptrre ad rpacdr'fc in your rrquast.
k : J
Qroup Policyboldat ma CitV of e-
Group PoUw Number( s) m-ps23 -9 If 7
Efi8ctivo bat. fot Aaandmant(r) J
Raquart tr hotr mad. =a Nostbutam National Liir fnaurmcr Campmy for th
rQVi8iOII{s) to 2 t Group ?eliefi ha) iadfc8trd rbava:
( If pO$Stbll, th. aff8UtfVl dae. tsf day of policy mgh)
pwwt'm TRB PUN IN a tQttLNINC UlR
1. Tb Polfcr Unit ( the rpl070.r md chair drpdoatr fa 8cwuat ma ) us no 1oa-r covorad Cor Bmlth banrfier throu@ NU?&
1. Th8 plica uait rif P 8tifl maintain thrit life and P~iaburrwont ac-t baadit8 ritb NyHt,
MJNt Will ~~EtinuO to ay Cot CfrhS'ahat WW8 LnCUSd b*f0?8 I/ 1/90,
\
(ti additional rpacm tr add, plauo uaa favar8O rid.)
bat@ JaauaxT 22 B 1990. Omup Peliewldar
By?& c
Tttlr, Saoior marunt Aarfyrc
PLUS% W; -t8n Natforrrrl Uta Xaru?mco -7 vi11 pw%b I# lf8h tho rwpwtd tnfrbm, pmidad At drma tho tuult to ba 1-1, for t 0 t .i -rrram plu iav017ed rsd acs8gerbh bud ea tu -it maat., au jIot to maam djtumt, if my, ia prwitv mtw. In ea.' d "T gp
Will Cmt-8 - -Ita
moa
I
’ ,:” $b’ 30 ‘92 17:35 NORTHWEST NQTL LIFE IN-S. : Lffa Inaurancr company b Himeaota SW0 I P.84 Routa No.
Effactivr Data for Amudmont(r) (If po#8~1., t&a offoctfva deto I We first &y of a policy month)
Raquut ia hueby mada to Northuartarn National Lifa Iaruraaco Company for the fobwing trvision(s) to ttm Group Polfuytiu) indiatad a&w:
Data. , 19,s
PraAaB Nam Ma~utun National Life Insurmca Company will provide amadamtC8) to
aC 7 lish thm to+utd rwiab~, pzovidad it dam the result to bo logal, approptiato fcgt t 0 l of irpsruanca plan fnvolvod md rcoeptrbh bared on it8 mdmvziting roqui.re- manta, 2 8 jmat to nocur8ry edjus~t, if any, in pr-ium rata8. In cam of problee, we will contut you promptly.
m 0 e
M NORTHWESTERN NATIONAL
LIFE INSURANCE COMPANY
HOME OFFICE * MINNEAPOLIS. MINNESOTA
!
CERTIFICATEBOOKLETRLDER
city of carbbad
GH-19235-0
Certain provisions in your certificate may be modified if you and your dependents were insured on the effective date of the Group Policy, January 1, 1986. These provisions are:
Pre-Exiafng Conditions
The pre-existing conditions provision in your certificate may not apply to you or your insured depen-
dent if the Group Policy replaces the Policyholder’s previous group health insurance policy. The pro-
vision does not apply to you or your insured dependent if all of these are true:
You or your insured dependent -
was insured under the Policyholder’s previous policy on the day before the Group Policy’s Ef-
becomes insured under the Group Policy on its Effective Date.
incurs an expense that would have been covered under the previous policy but is not covered
incurs the expense on or after the Group Policy‘s Effective Date.
fective Date.
under the Group Policy because of the pre-existing conditions provision.
When all of the above are me, we will pay a benefit equal to the 1- of the total expenses covered
under -
the previous policy, or .
the Group Policy, disregarding its pre-existing conditions provision.
flrlreover Deductfble and Out-of-Pocket Expcnscs
was insured under the Policyholder’s previous policy on the day before the Group Policy’s Effec-
met any part of the deductible or incurred any out-of-pocket expenses under the policy the
we will use that part of the deductible and the out-of-pocket expenses towards meeting the deducti-
ble and the out-of-pocket expenses under the Group Policy.
If you or your insured dependent -
tive Date, and
Group Policy replaced,
I
Registrar
NR-07886
w .rm NORTHWESTERN NATIO a
LIFE INSURANCE COMPANY
HOME OFFICE * MINNEAPOLIS. MINNESOTA
CERTIFICATEBOOKLETRIDER
city of CpILslmd
GH-19235-0
EMPLOYEE’S INSURANCE
The following provision is added to the Employee’s Insurance section of your certificate for Medic;
Insurance.
We waive the actively at work requirements of the Employee’s Insurance section of your certificate !
all of the following conditions are met:
You are eligible for insurance except for meeting the actively at work requirements on the Grou
You were insured under the group policy the Group Policy replaced on the day before the Grou
If these conditions are met, your insurance, including any Dependents’ Medical Insurance, will sta~
on the Effective Date of the Group Policy.
Policy’s Effective Date.
Policy’s Effective Date.
~chupenses8recovcredupensed
For Medical Insurance, we pay benefits only for expenses that were covered expenses under th
group medical policy which the Group Policy has replaced.
How much do we pay?
Before you return to active work, the benefit amounts and limits will be the same as the benefits UI
der the prior group policy. We reduce the amount we pay by any benefits still payable under the pric
group policy.
If you return to active work, we pay benefits according to the Schedule of Benefits and covered el
penses of your certificate.
When doer, your Mdd Insut.nce stop?
If you were not totally disabled on the day before the Group Policy‘s Effective Date, then your insu~
ance stops according to the “When does your insurance stop?” section of your certificate.
If you were totally disabled on the day before the Group Policy‘s Effective Date, your insurance stop
on the earlier of the following dates:
For Major Medical Insurance, the end of the 12 month period following the date you becam
For any other Medical Insurance, the end of the 90 day period following the date you becam
totally disabled.
totally disabled.
DEPENDENTS’ INSURANCE
The following provision is added to the Dependents’ Insurance section of your certificate for Medic;
Insurance.
We waive the requirement in the Dependents’ Insurance section of your certificate that a depender
must not be confined in a hospital in order to become insured, if dl of the following conditions ar
met:
Your dependent is eligible for insurance on the Group Policy‘s Effective Date, except for bein
Your dependent was insured under the group policy the Group Policy replaced on the day befor
If these conditions are met, your dependent’s insurance will start on the Effective Date of the Grou
Policy.
hospital confined.
the Group Policy‘s Effective Date.
NR-07887-1
I 0 0
a rm NORTHWESTERN NATIONAL
LIFE INSURANCE COMPANY
HOME OFFICE . MINNEAPOLIS MINNESOTA
CERTIFICATE BOOKLET RIDER
City of Carlsbad
GH-19235-0
Your certificate has been changed as follows. Please insert this rider in your certificate. This rider is
subject to all of the terms of the Group Policy.
I. Medical Insurance
A. The following provision under the Schedule of Benefits Major Medical Insurance “Maximum Life-
time Benefit” section on page 4 is deleted.
‘Your maximum lifetime benefit will decrease to $25,000 on your 70th birthday.
page 4 is changed to read as follows:
B. The “Deductible” provision under the Schedule of Benefits Major Medical Insurance section on
neductible
Tor an accidental injury ..................................................... none
,>r Non-Emergency Surgery Expenses for opinions
.lade by the second and third doctor ......................................... none
For Outpatient Preadmission Testing Expenses .................................. none
For Home Health Care Seryices Expenses ...................................... none
For Hospital Admission Expenses per admission
(if no preadmission certification is obtained) .................................... $250
For all other covered expenses:
. individual .............................................................. $100
family ................................................................. $300 Accumulation Period (January 1 through December 31) ...................... 12 months
C. The “Family Deductible” provision under the Schedule of Benefits Major Medical Insurance
section on page 4 is changed to read as follows:
: ;ly Deductible
amount used to meet the individual deductible for each member of your family is also used
irds meeting the family deductible.
L consider the deductible met by you and all your insured dependents for the rest of a benefit
period if two or more insured members of your family meet the family deductible in that benefit
period. If one insured member of your family meets the individual deductible, we consider the de-
ductible met for that insured member.
The carry over deductible does not apply.
-
NR.10455.1
.- * 0 a
,
rm NORTHWESTERN NATIONAL
LIFE INSURANCE COMPANY
HOME OFFICE , MINNEAPOLIS MINNESOTA
POLICY RIDER Issued by Northwestern National Life Insurance Company (NWNL)
This Rider is made a part of your policy, effective the date of NWNL's conversion to a stock life insur-
ance company, or, if later, the effective date of your policy.
Your policy is revised as follows:
This policy is nonparticipating and will not be entitled to share in the surplus earnings of NWNL.
After each policy year this policy, for purposes of determination of a retroactive rate credit, if any,
will be subject to experience rating with respect to the prior policy year. The experience rating plan
oc TNL in effect at the time of the experience rating will be used. The experience rating plan will
ti nto account those reserves and expenses which NWNL determines to be necessary and advis-
at NWNL, in its discretion, may combine the financial experience of this policy with the finan-
cia. dxperience of other group policies or coverages issued by NWNL to the policyholder. If a
retroactive rate credit results, it will be paid in cash to the policyholder.
Any conversion policy to which this policy refers is nonparticipating and will not be entitled to
share in the surplus earnings of NWNL.
NORTHWESTERN NATIONAL LIFE INSURANCE COMPANY
'4drz
resident
R-05362 399
;I
,
1
m 0 rm Northwestern
National Life
Home Office Minneapolis. MN
CERTIFICATE BOOKLET RIDER
City of Carlsbad
GL-19236-8
Your certificate C-2847 has been changed. The page attached replaces the one presently included in your ceR
icate. Please insert the new page into your certificate. This rider is subject to all of the terms of the Group
Policy.
Page 3 is replaced.
This Certificate Booklet Rider is effective on the latest of the following dates:
* July 1, 1991. - The effective date of your insurance.
The date you rem to active work if you are not actively at work on the date this Rider would otherwise st
(.
NC.2847
6 .I
-, e 0
8
SCHEDULE OF BENEFITS
BASIC LIFE INSURANCE
Class Amount of Life Insurance*
Active Mayor, Council Members
and Elected Officials
$25.000
City Manager, Assistant City Managers,
Department Heads and all other
Management Employees
All Other Active Employees
Two times your Basic Yearly .
Earnings** to a maximum of $200,000,
but not less than $15,000.
One times your Basic Yearly
Earnings** to a maximum of $200,000,
but not less than $15,OOO.
SUPPLEMENTAL LIFE INSURANCE
Class &mount of Life Insurance*
Active Mayor, Council Members
and Elected Officials
$25,000
Active Managers, Assistant Managers,
Department Heads and all other
Management Employees
All Other Active Employees
Two times your Basic Yearly Earnings**, but
the total amount of Basic and Supplemental Lifi
Insurance will not be over $4OO,OOO.'****
One times your Basic Yearly Earnings**, but
the total amount of Basic and Supplemental Lifi
Insurance will not be over $400,000.***
*Your amount of insurance will decrease to 65% on your 65th birthday.
**Basic Yearly Earnings means the basic yearly salary or wage you receive for work done for the Policyhol
It does not include bonuses, commissions, overtime pay, uniform allowances, car allowances, "stand-by" or '4
back" pay, educational incentive, or insurance rebate. To determine benefits, your amount of insurance is
rounded to the next higher $1,OOO multiple, unless the amount equals a $1 ,OOO multiple.
***For amounts of Supplemental Life Insurance or a combination of Basic and Supplemental Life Insurance t
$235,000, you must give us proof of good health we accept, without expense to us.
DEPENDENT LIFE INSURANCE
Class
Spouse
Amount of Insurance
$1,500
Child (each)
* under 6 months
6 months but less than 19 years,
Student age 19 but less than age 24.
$100
$1,500
Effective July 1,
.. J
t c
‘1
TO : Northwester a ational Life Lnsuranco Compan y. Box 20 - Minneapolis, Minnesota 55440
Request for Amendment of Group Policy(ies)
Rout
I
(Prepare in Triplicate)
Please be complete and specific in your request. 1 us Insurar
Group Policyholder CITY OF CARLSBAD
Group Policy Number(s) GL-19236-8
Effective Date for Amendment(s) 7/1/91 (If possible, the effective date should be the first day of a policy month)
Request is hereby made to Northwestern National Life Insurance Company for the fol revision(s) to the Group Policy(ies) indicated above:
Please amend the age reduction on our life plan as follows:
From:
65th birthday to age 70 NWNL pays 65%
70th birthday and after NWNL pays $1000
TO :
6Sth birthday and after NWNL pays 65%
(If additional space is needed, please use reverse side)
Date ye 3 , 19 ?/ . Group Policyholder 7 c /I’ 0 CARU
BY
Title CoMpCh!!
PLEASE NOTE: Northwestern National Life Insurance Company will provide amendmc accomplish the requested revisions, provided it deems the result to be legal, apI for the type of insurance plan involved and acceptable based on its underwriting ments, subject to necessary adjustment, if any, in premium rates. In case of prc will contact you promptly.
12024