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HomeMy WebLinkAboutResolution_82-06/07_09/13/2007 RESOLUTION NO. 82-06/07 A RESOLUTION OF THE VILLAGE COUNCIL OF THE VILLAGE OF TEQUESTA, PALM BEACH COUNTY, FLORIDA, TO RENEW AONE- YEAR CONTRACT FOR DENTAL INSURANCE WITH GUARDIAN, IN THE APPROXIMATE AMOUNT OF $31,406.00 FOR FY 2007/2008 WITH BUDGET ALLOCATION FROM GENERAL FUNDS, WATER UTILITIES AND STORMWATER FUNDS, AND AUTHORIZING THE VILLAGE MANAGER TO EXECUTE THE CONTRACT ON BEHALF OF THE VILLAGE WHEREAS, the Village has been with Guardian Insurance for the 2006/07 Fiscal year and have experienced satisfactory levels of service; and WHEREAS, the Village has reviewed the major carriers in the market and have not found a significant difference in the offerings and costs as outlined in "Exhibit "A" NOW, THEREFORE, BE IT ORDAINED BY THE VILLAGE COUNCIL OF THE VILLAGE OF TEQUESTA, PALM BEACH COUNTY, FLORIDA, AS FOLLOWS: Section 1 Consideration is given to Resolution No. 82-06/07 to renew dental insurance coverage services with Guardian for FY 2007/08 and the Village Manager of the Village of Tequesta be authorized to execute renewal on behalf of the Village. Section 2 This Resolution shall become effective immediately upon passage. The foregoing Resolution was offered by Vice-Mayor Watkins who moved its adoption. The motion was seconded by Council Member Turnquest and upon being put to a vote, the vote was as follows: For Adoption Against Adoption Mayor Jim Humpage X Vice-Mayor Pat Watkins X Council Member Dan Amero X Council Member Tom Paterno X Council Member Calvin Turnquest X The Mayor thereupon declared the Resolution duly passed and adopted this 13 day of September, 2007. MAYOR OF TE a Humpage ATTEST: ~,~i~a~ ra!~~s, ~`°~,~ ~ ~ Ted? °~~i Lori McWilliams, CMC . = : ~' ~/~~~ ~~' ' Village Clerk ° °-,~~c~~~c~nT~ ~: Q m X W d F~ a C7 w o ° ~ r. `'9 o 0 0 0 0 0 0 0 ~ ~ z 0 Vl 0 00 ~n ~n (.~ W N ~ M ~--i z o O sa o ~ rn M ~ --+ v~ p O ~ ~ ~`~' o0 p~r ~ '-. 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E.q Z ~ ~1 ~ , O > , , ~ ~ ' d G C ~ ~"~ A a ~ 0 W ~ W W a, a a 0 C a 7 A ^ o w .~ O ~ 'b ~ M Eft ~ ~ 4.r O a i a ~i .o Y ~ ~ . v ~ y 0 O °' U U G 0 °' u 0 ~ a w o ~ w ~ ~ c O D U o ~, ° o _ ~ C "_" a x ~ ~ O °- ~ ~ 0 U (/] ~ c~ ~ p 0 ~ ~ ~~ b 'L7 [ ~ ~ o c ~ ~ 3 E ~ ~~ ~ . ~~ ~ ~ q a Q~ fr'" cV QJ SPECIFICATIONS FOR A ~~%% ^ Noon a~ atr~ o Nbdwest aegp~ os~e v we5ten, aeg~ otr+w ^ e,;dgevrate~ otr~ NON MEDICAL PLAN GUARD 1 A N ~ PO Box 26040 PO l3aa 8012 PO Box ZA54 PO aox 425 LeregnvalleyPA16002-6040 ApplasMW154912~012 SpokenaWA9 921 0-24 5A E.BridgavralerMA0z333-0425 OF GROUP INSURANCE Please Print GROUP PLAN NUMBER {Guardian Use Only) ® New Plan ^ Change of Plan Requested effective date: 1011/06 SECTION 1 PLANHOLDER INFORMATION Planholder Name (full legal name of company) ~[lage of Tequesta Tax I.D. # 59-6044081 Main Address (street, city, state, zip) 250 Tequesta Dr., Suite 300, Tequesta, FL 33469.0273 Mailing Address {street, city, state, zip) Same ---- Name of Correspondent 8 Title: Phone No: 5fi7-575-6200 Robbie Russo HR Generapst Fax No. 561-575-ii203 Type of organization: ^ Corporation ^ Partnership ^ Proprietorship ®Other (explain) Municipality Include eligible employees who work: ®30 Hrs/Wk ^ Other Number of full-time employees: No. of full-time employees to be insured: Total number of employees: Are ail full-time employees to be included? ®Yes ^ No Indicate class or classes to be excluded: Premium Paid ®Monthly ^ Quarterly ^ Annual ^ Semi Annual For plans with less than 10 employees: ^ GOM ^ Annual Depasii ~ 3,994.40 Nature of business (specify} Municipalilty Oate Est. 50+ year SIC: Affiliates, subsidiaries or branches (legal name & location) Nature of business/ T e of Or anization No. of full-time emp's in this com an No. of full-time emp's to be insured nIa SECTION II SUPPLEMENTARY INFORMATION (All questions must be answered) 1. Has this firm or any of its affiliates, either under its present name or under any other name, ever applied for group insurance with Guardian or The Guardian insurance and Annuity Company, inc.? ^Yes ~ No if °yes°, furnish name of employer, plan number and date of cancellation: 2. Name of present or prior group carrier. FL Municipal Trust Cancellation Daie: 9130106 What coverages are now or were in force? ^ Life ^ Medical ®Oental ^ Prescription Drug ^ Utsion n Short Term Disability C-1 Lono Term Disability (Please attach copies of booklet and current billing statemenfj 3. For plans requesting life insurance: Is the disability waiver of premium benefit io be included? ^Yes ^ No Will this insurance re lace an existin life insurance or annuit 7 'Pc ^Yes ^ No 4. if present carrier provided life insurance, are extended benefits provided in case of disability? ~.A ^Yes ^ No 5. To the best of your knowfedge are any emplayees or dependents currently disabled? tf "yes°, please indicate: [] Yes ®No ^ actively at work ^ on disability leavelclaim ^ o#her (please provide details on back of farm) Far plans with less than 100 eligible employees: To the best of your knowledge has any employee or dependent within the past three years, been treated for or diagnosed as having: cancer, heart disease; kidney disorder, stroke or ^ Yes ~ No other serious disease? . For plans with less than 100 eligible employees: To the best of your knowledge has any employee or dependent, ^Yes ~] No been diagnosed as having AIDS or AIDS Related Complex? For plans with Jess than 50© eligfble employees: To the best of your knowledge has any employee or dependent, within the past two years, suffered a condition which resulted in a health insurance claim of $25,000 or greater {$50,000 ^ Yes, No or greater for plans with more than 100 eligible employees)? nr~ nw nc-.-r rt se mvt on nr++rww rr. r.r..-. T~ un rur.nr ..~....'+.+..+.. t..rv n..... ... +-~- •...... ..,r ........~..~.... ~...... +.... .. r. ,.-.....- -....... If any questions in Section II of this form were answered "yes", please provide an explanation using the additional space below. Refer to the specific question number, and give details including names where appropriate. If additional space is needed, use a separate sheet of paper, and refer to the question number. Be sure to sign, date and have ii witnessed. Question No. F-xplanation SECTION III COVERAGE Ei_ECTION Insurance to be issued: "N" for non contributory or "C" for contributory. If "C" indicate % of employee contribution. Employee: Life % Dental N % Vision % STD % LTD Dependent: Life % Dental G % Vision % ~ ~ ~ ~ - - - - SECTION 1V AGENT INFORMATlON1SlGNATURE 1) Agent Name: Steven Olsen 100% Code: Guardian Agcy: Code: Agent Address: 507 5 Flagler Dr., Suite 604, West Palm Beach, FL 33401 SUeet City State Zip Code For Jffe Insuranc 1 : To the best of your knowledge, will #his insurance replace any existing life insurance or annuity? ^ Yes ^ No Agent Signature ~ ~ Soc. Sec. # 363-82.3280 Tax ID # 94-3130804 2) Agent Name: % Code: Guardian Agcy: Code: Agent Address: Street City State Zip Code Forllfe Insurance only: To the best of your knowledge, will this insurance replace any existing life insurance or annuity? ^ Yes ^ No Agent Signature Sales Office Soc. Sec. # Tax ID # Sales Representative Code SECTION V AGREEMENT Request for Participation In A Certain Trust Agreement The undersigned planholder engaged primarily in the industry described in Section I, hereby requests that it be approved as a participant in the Trust established by other Planholders engaged in the same industry for the purpose of purchasing insurance for the benefit of their employees and requests inclusion as a participant under the Group Insurance Plans} issued to the Trustee for the plan{s} of insurance shown above in Section III. Conditions of Agreement It is understood that no individual shall become insured while not actively at work on a full-time basis, and only full-time employees shall be eligible. Full-time employee means one who regularly works the number of hours in the normal work week established by this planholder {buf not less than 30 hours per week) at his planholder=s place of business. It is further understood that no agent has power on behalf of The Guardian Life Insurance Co. of America to make or modify any request or application for lnsurance, or to bind said Insurance Company by making any promise or representation or by giving or receiving any information. It is further understood that no insurance will be effective until the plan is accepted in writing by the lnsurance Company. No contract of insurance is io be implied in any way on the basis of the completion and submission of the specifications shown on both sides of this form. "Any person who knowingly and with intent to injure, defraud or deceive any insurer files a stalemeni of claim or an application containing any false, incomplete or misleading information is guilty of a felony of the third degree". I have reviewed the statements made by me on this application, and they are true and Signature and Title of Officer D ~~ Partner or Proprietor. T,~~ • U ~~G Print Name c or Proprietor Signature of Date: ~ y~ o~ Qate: ~ .~ ~rt-' C City and State Where Signed: Tequesta, FL The Guardian Life Insurance Company of Amerkea ^ Nonhea5litpglonalOtece D EdidwW RegioaalOifice O WestemRegiwml0lEea i] &idQawaterOlfice GUARDIAN' Leti~gh Valley PA 18002-6040 Appblon w, 54952-8012 Spokane WA 9921.2454 Et3~id0 4mreSer MA Q2333~0425 CONSENT FOR DELIVERY OF ELECTRONIC PLAN DOCUMENTS I, ~\lkt~~ ~t~2~... O , an authorized representative of y~~Zr~ U)< IEt~3t'S'i~ , coup ame) consent to the electronic delivery of insurance certificates, riderslpolicies issued by Guardian in connection with the group plan by the following: PDF file via a-mail: Please provide a-mail address: t`Z~USSc~ (!~ ~ ~~• O~U ^ PDF file on a floppy disk: Please provide mailing address: ( understand that Guardian will provide one paper copy of each certificate and riderlpolicy for this plan in addition to the electronic documents. By signing this consent, I, on behalf of the Planhalder, agree to the following: (1) make an electronic version of the applicable certificate readily available to each covered person; (2} produce and distribute paper copies of the certificates to any covered person who does not have ready access to the electronic version of the certificate; (3) make electronic certificates available to covered persons, in the following way(s) (e.g. company Intranet under Employee Benefits) : ~~,n~'t l9F 'l; C,~VE- m ~~ (4) maintain the integrity of the information contained in the plan documents and will oat alter the content in any way. In the event of any conflict, the terms and conditions set forth in the riderlpolicy, as issued by Guardian, will determine benefits. Dated: `- ~ "~~ By: Prin Title Planholder's Name: y ~u..AG~ OF ~ - ©y~s~f1 Plan # '~~~ GG-013902 (3103}