HomeMy WebLinkAboutPC March 30, 1993
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CITY of ANDOVER
1685 CROSSTOWN BOULEVARD N.W. . ANDOVER, MINNESOTA 55304 . (612) 755-5100
PERSONNEL COMMITTEE MEETING - March 30, 1993
7:30 P.M.
AGENDA
1. Fire Department Officer Salaries
2. Employee Benefits
A. Dental Insurance
B. Disability Insurance
C. Cafeteria plan - I.R.S. Code 125
D. Deferred Compensation - I.R.S. Code 457
E. Health Insurance Contribution
- General City Employees
3. Payroll Procedures - Electronic Bank Deposits
4. Weekend Duty Pay - Supervisors
Adjournment
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CITY of ANDOVER
1685 CROSSTOWN BOULEVARD NW. . ANDOVER, MINNESOTA 55304. (612) 755-5100
MEMORANDUM
TO:
COPIES TO:
FROM:
DATE:
Personnel Committee/Don Jacobson & Jack McKelvey
March 10, 1993
Daryl Sulander, Da
James E. Schrantz
REFERENCE: Fire Department Officers Salaries, etc.
Per the Committees request I have checked with Bill Hawkins concerning
the effect of a monthly pay increase for the Fire Department officers
that are currently being payed and the effect of paying additional
Fire Department officers.
Bill believes that their pay will have no effect on their status.
I talked to Cy Smythe the City's Labor Consultant. Cy said only the
\ number of hours that are worked per week affect firefighters status.
) If they work over 14 hours per week they could form a union.
I have concerns about benefits that various officers could be eligible
for such as insurance. City employees are eligible for health
insurance at 30 hours/week.
I believe that due to various concerns that have been experience by
other cities for overtime, etc., we should have an expert review the
city's personnel policy concerning the volunteer fire department.
I The problem a few years ago concerned the city employee firefighters
getting overtime after 40 hours, at that time we looked at points
being payed, one point per call. Bill said that the points were
expenses for responding to the call - but the department gets paid for
these points as wages not as expenses.
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The personnel policy should state that volunteers have different
status and/or benefits than (regular) city employees.
We are also looking at our hiring practices for the fire department.
The department needs some criteria spelled out for the membership to
consider when they vote on a member. They need to add criteria that
relates to compatability but it needs to be stated so it is not a
popularity appointment. I have asked Karen Olson, Cy's partner to
look at the criteria for the City (Cy is on vacation).
We should also do a background search on the applicants. The
application form we are using at City Hall which I received from the
Anoka County Job Service, is attached. This application addresses
conviction records.
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CITY of ANDOVER
1685 CROSSTOWN BOULEVARD N.W. . ANDOVER, MINNESOTA 55304 . (612) 755-5100
MEMORANDUM
TO:
COPIES TO:
FROM:
DATE:
Personnel Committee/Don Jacobson & Jack McKelvey
Jim Schrantz, Dale Mashuga
Daryl sulander~~
March 12, 1993
REFERENCE: Fire Department Salaries & point Pay
500 calls average 6 at $7.25/hr.
500 calls average 5 at $9.50/hr.
21,750
23,750
45,500
Proposed
39,875
Current
3,250
25,800
35,000
3,100
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Officer Salary
Drills & Meetings
(2.25 x 12 x 11 x 18)
Misc. work (clean-up, etc.)
(Officers 6 x 11 x $2.25/hr.) Annual
8,100
40,400
Committee Meetings
3 pts x 15 x 11 x $2.25/pt
($1114.00 + 2100)
3,214
2,100
100,464
105,875
Less: Jan/Feb 1993 at current
rates for office pay
2,950
102,925
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March 17, 1993
Daryl Sulander
City of Andover
1685 Crosstown Blvd. NW
Anoka, MN 55304
:t+E-M. d.A.
HealthPanners
2829 University Avenue Southeast
Minneapolis, Minnesota 55414
612-623-8400
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Dear Daryl:
Thank you for your inquiry about the dental benefits available through the
Anoka County purchasing agreement.
The enclosed brochure describes benefits, locations and general
information regarding coverage in the Group Health Dental program.
Employees are eligible after one year of full-time employment. Employees
who have eligible dependents must include them when first eligible if they
want coverage for them. Their is no open enrollment in dental. The only
exception is that dependents who are covered under a group plan through
the spouse of an employee. If that coverage is terminated involuntarily the
employee could add dependents at that time.
Current rates through August 1993 are:
Employee
Employee with dependents
Please give me a call if you have any questions.
Sincerely, 4 ~
Uames S. Erlandson
Senior Account Manager
Enclosure
JSE{dmg
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$20.53
$55.45
Ti,e He.zlt"P.lrtllers f:mlz1y 0( '-'e'7Ith plans incllldes Grollp He,zlt" .l/ld .\ledCenters.
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.' Dental Benefit Summary
..GROl'P
..HEAJ..:fH
..I~C:
Anoka County
DENTAL OPTIONS
(DUAL CHOICE)
With Ootion A only, there are no claim forms, no deductible for in-service area
dental care and no annual maximum dental benefits. Services of dentists other
than Group Health, Inc. dentists are not covered except upon authorized
referral. For exact coverage terms and conditions, consult a Group Health
Dental membership contract. Out of service area emergency services are provided
with a $25 deductible per member per calendar year.
With Option B, services are provided by the dentists of your choice. Teeth
missing prior to the effective.~ate of coverage are not covered. No deductible
for preventive and diagnostic care. Pre-authorization for any care over $300 is
is necessary. Annual maximum dental benefits of $750.
Options A and B are mutually exclusive throughout a contract year.
OPTION A
COVERAGE
OPTION B
COVERAGE
PREVENTIVE AND DIAGNOSTIC CARE
Teeth Cleaning
Examination
Dental X-rays
Fluoride Treatments
Oral Hygiene Instruction
Pit and Fissure Sealants
100%
100"1.
100%
lOO~~
1 OO~~
100%
100%
100~~
100%
100%
100%
100%
Annual Deductible
None
$25-3 per family
REGULAR AND RESTORATIVE CARE
Fillings
Ora 1 Surge ry
Periodontics (Gum Treatment)
Endodontics (Root Canal Therapy)
80~~
80~~
80%
BO%
80%
80%
80%
BO%
SPSCIAL RESTORATIVE CARE
Restorative Crowns
Inlays
Onlays
75%
75%
75%
50%
50%
50%
PROSTHETICS
Bridges
Dentures
Partial Dentures
50i~
50~~
50~~
50%
50%
50%
ORTHODONTICS
$400 maximum lifetime benefit for eli-
gible dependents through age 1B whose
orthodontic treatment begins after the
effective date of their contract.
50%
No coverage
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OUT OF SERVICE AREA-EMERGENCY SERVICES
Dental X-rays
Regular and Restorative Care
Special ~estorative Care
80%
BO%
75~.
Same as above
Same as above
Same as above
32/88
..GROUP
.. HEALTH
..INC.
2829 UNIVERSITY AVE.. S.E. MINNEAPOUS. MN 5541~295
GROUP HEALTH. INC. DENTAL OPTIONSsm PLAN
Group Health. Inc. is a)eader in prepaid dental plans. Group Health
provides comprehensive dental coverage to over 59.000 Twin Cities
residents. Group Health's Dental Options plan provides members the option
of using Group Health or other dentists.
Key benefits of using Group Health dentists include:
I
. Group Health dentists and dental centers are among the finest in the
country. Our professional staff includes general dentists as well as
specialists in root canal treatment. gum disease and children's dentistry.
. There are no prior authorization forms and no claim forms. Members
receive dental care without the paperwork hassles.
. Emergency care is available 24 hours a day. One of our dentists is on call
through our After-hours Care Team Service at all times.
. Our dental center hours are convenient. Schedules vary by clinic. Our
centers are open evenings and Saturdays.
. No annual maximum on restorative care.
When a member decides to use non-Group Health dentists. key advantages
include:
. An unlimited choice of dentists. Members choose any dentist for their
dental care.
. Excellent coverage. Members have coverage for preventive care: then.
following a deductible. restorative and prosthetic care are covered with
copayments.
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Group Health. me. lDoksfarward to meeting your.furure dental aIre needs.
J
AN EOUAL OPPCRTIJNITY EMPLOYER
-'lit-
..GROUP
..HEALTH
..INC.
2829 UNIVERSITY AVE.. S.E. MINNEAPOUS. MN 55~14-3295
DentaJ Plans
Services Not Covered
o Dental services provided inside the service area by non-GHI dentists. unless authorized as a referral
dental service. This exclusion does not apply if you are covered under Option B of a Dental Options
pan. ~.
o Dental services which are performed primarily for cosmetic purposes.
o Hospitalization for any purpose.
o Anesthesia required for dental services. unless it is administered by a GHI dentist or by a referral
provider for covered dental services.
All orthodontic services not provided for in the Contract.
\ Orthognathic surgery (surgery to reposition the jaws) not specifically provided for in the Contract.
o Investigative or experimental procedures. or dental services not otherwise clinically accepted.
o Procedures. appliances or restorations that are necessary to alter. restore or maintain occlusion.
including but not limited to: increasing vertical dimension. replacing or stabilizing tooth stnJctlJre lost
by attrition. realigning teeth. periodontal splinting and gnathologic recordings. Mandibular orthopedic
appiiances and bite planes are also not covered. All charges related to the services set forth in this
paragraph are a member co-payment unless covered under a separate GHI Memoership Contract.
The replacement of any prosthetic or orthodontic appliance which is misplaced. lost or stolen.
o Charges for programs of treatment, including prosthetics. which began prior to a member's effective
date.
o Dental services. dental supplies. and dental devices not expressly covered as a benefit are not
covered.
For exact coverage terms and conditions, consult a Dental Membership Contract.
3/91
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AN EOUAL OPPORTUNITY EMPLOYER
-...
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CONSUMER INFORMATION
Dental Plans
Important Consumer Information
Covered Semcn: Services provided by Group Health, (ne. will be c:overed only if services are provided by participating
Group Health. Ine. providers or authorized by Group Health. Ine. Your contract fully defines what services are covered
and describes procedures you must follow to obtain c:overagL
ProridelS: Enrolling in Group Health. Inc. does not guarantee services by a particular provider on the list of providers.
When a provider is no longer part of Group Health, Ine., you must ctJoose among remaining Group Health. Ine.
providers.
Referrals: Cartain services are covered only upon referral. See your contract for referral requirements. All referrals to
non-Group Health. Inc. providers and certain types of health care providers must be authorized by Group Health, Ine.
Emergency Semces: Emergency serYic:n from providers who are not affiliated with Group Health. Inc. will be covered
only if proper procedures are followed. Your contract explains the procedunts and benefits associated with emergency
cere from Group Health. Inc. and no~roup Health. Ine. providers.
Exclusions: Cartaln semces or medlceisupplles are not COVIH'lIC1. You should read the contract far a detailed
explanation of all exclusions.
Continuation: You may convert to an indlvldusl health maintenance organization contract or continue coverage under
certain cin:umstances. These continuation ard conversion riglrts are explained fully in your contract.
Cancellation: Your COYBrIIg8 may be canceled by.you ar Group Health. (ne. only under certain conditions. Your contract
describes all reasons far cancellation of ccmKlIgL
Member Bill of RIQhts
The laws of the Slate of Minnesota provide members of health maintenance organizations (HMOs) certain legal rights.
including the fallowing:
, Members have the right to available and accessible services including emergency services 24 hours a clay and seven
I days a weelc:
Members haYtl the right to be infanned of health problems and to receive information regarding treatment altematiYtls
and risks whictJ is sufficient to assure infanned ctJoic:e;
Members have the right to refuse treatment and the right to privacy of medical and financial records maintained by
Group Heafth. Ine. and its health care providers. in accordance with existing law;
Members have the right to file a grievance with Group Health. Inc. and the Commissioner of Health and the right to
initiate a legal proceeding when experiencing a problem with Group Health, Ine. or its health care providers:
Members have the right to a grace period of 31 clays far the payment of eadl premium far an individual health
maintenance contract failing due after the first premium. during whidl period the contract shall continue in larce;
Members have the right to cancel an individual (non-groupi contract and receiYtl a full premium refund if cancellation is
made within 10 days of receiving the con1ract. Howner. any cialms incurred by a member prior to the cancellaticn will
be the member's responsibility;
Medicare enrollees have the right to VOluntarily dlsenroll from the health maintenanea organization and the right not to
be requested or encouraged to dlsenroll except In circumstances specified In federal law; and
Medicare enrollees haYtl the right to a clear description of nursing home and home care benefits covered by the health
maintenance organization.
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This health care plan may not cover all your health care expenses. Read your contract carefully to determine whictJ ex.
penses are covered.
Any complaints about a presentation made by a Group Health. Inc. representative can be submitted to Group Health. the
Department of Health or your employer.
..GROl'P
.. HE<\LTH
..INC.
1189
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Accident and Disability Insurance Proposals 3/30/93
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American Family Life
Assurance Company (AFLAC)
Colonial Life and
Accident Insurance Company
-----------------------------
--------------------------
Bi-weekly premium
$11.16
Monthly premium $23.05
or $24.00
or $25.95
------
$276.60
or $288.00
or $311.40
Based on Income Benefit
Annual cost
$290.16
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INCOME SECURITY PROGRAM
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Accident/Disability Insurance
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Insuring Over 35 Million PeoPle Worldwide
Form A.14438B-7
Protects You 6 Ways
rg Ambulance Benefit
fJi1 Emergency Benefit
fJi1 Lump-Sum Injury Benefits
f!4 Hospital Benefits
f1il' Disability Income Benefits
f1il' Accidental Death Benefits
Accident/Disability Insurance
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Accident/Disability only Insurance Policy Series A-30000 with Rider Series A-30050
';''":~~'''-.
While this every-
day scene looks
harmless enough,
it is the setting
ofmiUions of
accidents each
year.
$50,000 ifde:uh results from an accident on acommon carrier
(public transportation such :IS buses. trolleys. trains
:lnd airplanes).
$30,000 if death results from a covered motorized vehicle
or pedestrian accident. Vehicles must be properly
licensed to tra\'e! on Liry. state and federal roads.
$15,000 if death result~ from other types of accident.
"-
Death must occur within '.>0 days as the result of a covered
accident while cO\'erage is in toree. These benefit amounts
apnly only to the primary insured. See Umitations & E.xclusions.
Death bendits will be paid to your beneficiary or estate. Other
beneths will be paid directly to you unless assigned.
PL.\;" I pays one.half 0;2) of the above benefits.
~J~(J("JjmU:1"J:1~.1_
If you are confined in the hospital due to a covered injury, we
will pay. Benetlts up to 365 days per injury.
PIAN II - $350 a week ($50 per day)
PL{LV I - 5210 a week (530 per day)
These benetlt amounts apply only to the primary insured.
Successive contlnements not separated by six months or
more will be considered a continuation of the initial confine-
ment. Hospital confinement must occur within 30 days of the
covered accident. The term hospital does not include hos-
pice. convalescent. mental or extended care facilities. or
facilities used for drug or alcoholic rehabilitation.
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This benefit will be paid if you are injured in a covered
accident and require transportation to a hospital.
PLAN II 550 PLAN I 525
This benefit amount applies to the primary insured. You must
be taken to the hospital by a licensed professional ambulance
service within ...8 hours after the accident.
.,.. Every 4 seconds un .4merican is injured in an
accident!
.,.. 8.800.000 suffered disabling injuries in a one-)'ear
period!
.,.. 3,100.000 Americans were injured in a year in
their own homes!
.,.. $2].2 billion was spent in a year for medical
expenses for accident victims!
Source: Accident Facts - National Safety Council 1988
EMERGENCYBENEEEr" .
Treatment by a doctor. x-rays or examination and treatment
in a hospital emergency room. We will pay the following
amounts for each covered accident:
PLAN II
$60
PLW 1530
Treatment must be received within ~8 hours after a covered
accident. This benetlt amount applies to the primary insured.
~:f:1'1J:1~Mf;JI:-IIIJ~
Disability Coverage
(For the Sarned Insured)
L'p to age 7'0. if you have a full-time job and due to an accident
that occurred off the job are totally disabled. we will pay this
bendltforupto 12 months (365 days) while you reco\'er . Or.
if you are not working full-time when you become disablLd.
we will pay this benefit when contlned at home or in a
hospital up to age 65.
~ $750 monthly (525.00 daily) Rider II
~ $450 monthly ($15.00 daily) Rider I
At age 65. or 70 if still working. this benefit converts to a
hospital confinement benefit. If confined due to an accident.
we will pay:
o 52,250 monthly (575.00 daily) Rider II
o 51,350 monthly ($45.00 daily) Rider I
Disability must occur within 90 days of the accident. You
must be under the care of a physician. The disability rider
terminates on death of primary insured.
Hospital Confinement Coverage
(Family Members)
Family coverage benefits under this rider provide benefits
for each other covered family member when hospitalized
due to a covered accident. We will pay:
o 5300 monthly (510.00 daily)
Confinement must occur within 90 days of the accident.
Refer to insertfonn A-14439 for complete details on spouse and dependent children coverage.
LUMP-SUM INJURY BENEFITS
If an insured person receives more than one fractUred bone. one dislocation. or fractUre and dislocation in a covered accident
and requires open or closed reduction, we will pay one-and-one-half times the highest benefit amount. No other amount will
be payable under these benefits. If a dislocation is reduced without anesthesia, we will pay 25% of the amount shown. .. Benefits
are payable only for the first dislocation of a joint. If an insured person dislocates a joint before the effective date of coverage
and the insured person dislocates the same joint again, it will not be covered by this policy. In the event that death and
dismemberment/injury result from the same accident, only the death benefit will be paid. Loss must occur within 90 days of
the accident unless otherwise specified. If you have a family policy, the benefits listed below apply to the insured and spouse.
Most benefits for covered dependent children are one-half of these amounts.
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Dismemberment or Comolete Loss of with or without
reattachment:
1. Both anus and legs. . . . . . . . . . . . . . . . . . . . . . . . . . . .. .
2, Both eyes. . . . . . . . . , . . . . . . . . . . . . , . . . , . . , , ., '"
3. Both hands. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4. Both feet. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5. Both legs. . . . . . . . . . , , , , . . . . . . , . , , . , , . . . . .. , . , . .
6. Both anus. . . . . . . , , . . . , . . . . . . . . . . . . . . . . . . , ,. . . .
7. One arm or one leg. . . . , . . . . . . . . . . . . .... ... .. . . .
8. One eye. . . . . . . . , , . . . . . . . . . . . . . . . . . . . . . . . . .. . . .
9. One hand. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
10. One foot. . , . . . . . . . . . . . . . . . . . . . . . . . , . . . . . . . . . . .
FractUreS (chit' fractures oav 10"10 of amount shown):'
1. Hip:
open reduction, , . . . . . . . . , . . . . . . . . . , . . . . . . . . . . .
closed reduction. . . . . . . . . . , . . . . . . . . . . . . . . .....
2, Pelvis (excluding coccyx):
open reduction. . . . . . . . . . . . . . . . . . . . . . . . . . .
closed reduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3. Leg:
open reduction. . . . . . . . . . .. ...,.,........... . . .
closed reduction. . , . . . . . . , . . . . . . . . , . . , . . . . .. ..
4. Skull:
depressed, .. . .. . .. . . . . . . . .. .. . . . . . . . .. .. ..
simple. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5. Hand (excluding fingers), foot (excluding toes
and heel), shoulder blade, forearm, ankle, elbow,
kneecap, wrist, sternum or lower jaw:
open reduction. . . . , , . . . . . . , , , . , . . . . . . . . . . .. ..
closed reduction. . . . . . . . . . . . . . . . . . . . . . . . . . . .
6. Vertebrae (body ot). . . . , . . . . . . , . . . . . . . . . .. .. ..
7. Upper jaw, upper arm or flce (excluding nose):
open reduction. . . . . . . . . . . . . . . . . . . . . . . . . . .. ..
closed reduction. , . . . . . . . . . . . . . . . . . . . . . . . . . .
8. Rib or ribs, coccyx, nose, toe or toes, heel,
finger or fingers:
open reduction. . . . . . . . . . . . , . . . . , . . , . . , . . . . . .
closed reduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
9. Vertebral process:
open reduction. . , . . , . , . , . . , , , . . . , . , . . . . . . . . .
closed reduction. . . . . . . . . . . . . . . . . . . . . . . . . .. ..
Dislocations which are reduced under l!eneral anesthesia
1. Hip:
open reduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
closed reduction. . . . . . . . . . . . , . . . . . . . , . . . . . , . . .
2, Knee or shoulder:
open reduction. . . . , . . . . . . . . . . . . . . . . . . . . . . . . . .
closed reduction. . . . . . . . . . . . . . , . . . . . . . . . . .. ...
3. Collar bone:
sterno
open reduction. . . . , . . . . . . . . . . , . . . . , . , . . , . , . .
closed reduction. . . . . . . . . . . . . . . . , . . . . . . . . . .. ..
acromio or acromio-sepc
open reduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
closed reduction. . . . . . . . . . . . . . . . . . . . . . . . , . . . ,
~" -'
J
'.
I
, PlAN n PIAN I
~'
.
$25,000 $12,500
10,000 5,000 '
10,000 5,000 "
10,000 ~5,000 "
10,000 -.~5,OOO
10,000 5,000
4,000 2,000
4,000 2,000
4,000 2,000
4,000 2,000
2,000 1,000
1,000 500
1,000 500
800 400
1,000 500
500 250
800 400
300 150
800 400
400 200
900 450
600 300
300 150
160 80
80 40
300 150
150 75
2,000 1,000
1,000 500
1,000 500
500 250
1,000 500
;00 250
800 400
400 200
This is a brief summary of coverage. Refer to policy for details.
'\
I
4. Ankle or foot (excluding toes):
open reduction. . . . . . . . . . . . . . . . . . . . . . . . , . . . . . . . . .
, closed reduction. . . . . . . . . . . . . . . . . . . . . . . . . .. ., . . . .
5. Hand (excluding fingers):
open reduction, . . . . . . . . . . , . . . . . . . . . . . . . . . ... . . . .
closed reduction. . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . .
6. Lower jaw:
open reduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . , .
closed reduction. . . . . . . . , . . . , . . . . . . , . . . . . . . . . .. . .
7. Wrist or elbow:
open reduction.. .. .. . . .. . .. .. , .. .. .. _ .. . .. . . .. . .
closed reduction. . . . . . . . . . . . . . . . . . . . . . . , . . . . . . . . .
8. Toe or finger:
open reduction. . , . . . . . . . . , . . . . . . . . . . . . . . . . . . . . . .
closed reduction. . . . . . . . . . . . , . . . . . . . . . . . . . . .. . . . .
Internal iniuries resultinll in ooeD abdominal
or thoracic sun!:erv:. . . . . . . . . . . . . . . . . . . . . . , . . . . . . . .
Tendons and ligaments:
Tendons or ligaments must be torn, ruptured
or severed and must be repaired through surgery
by a physician within 90 days after the accident.
1. Repair of one. . . . . . . . , , . . . . , . . . . . . . , . , . . . . . . . , . .
2. Repair of all if more than one. . . . . .. .. . .. . . . . . . . . . .
!rn!:m: (treated by a physician within 72 hours
after the accident)
1. Second-degree bums of at least 25% but not more
than 35% of body surface. ........ .. ........, .. . . ..
2. Second-degree burns of more than 35%
of body surface. . . . . . , . . . . . . . . . . . . . . . . .,... ... . . .
3. Third-degree burns covering six through
10 square inches of the body surface. . . . . . . . . . .. . . . .
4. Third-degree burns covering more than 10
square inches of body surface. . . . ., . , . . . . . , . , . .. . . .
RU(ltured disc or tom knee cartilaI!e (must be
treated by a physician within 60 days after the
accident and repaired through surgery within
one year after the accident)
Injury during first year of coverage. . . . . , . . . . . . . . . . . .
Thereafter. . . . . . . . . . . . . . . . . . . . . . . . . . . , . . . . . . . . . .
Eve iniurv with sun!ical renair:. . . . . . . . . . . . . . . . . . . . . . .
Lacerations reQUirinlZ suture (must be repaired
within 72 hours after the accident):
1. Single laceration less than two inches. . . . . . . . . . . . , . . .
2. At least two inches but not more than six inches
. (total of all lacerations). . . . . . . . . . . . . . . . . . . , , , . . . . .
3. Over six inches (total of all lacerations). . . . . . , . . . . . . .
Loss of finllen s) or toe( s) with or without
reattachment:
1. One finger or one toe (dismemberment). . . . . . . .. . . . .
2. Two or more fingers anellor toes
(dismemberment). . , . . . . . . . . . . . . . . . . . . . , . . . . . . . .
3. Partial loss of one finger or toe. . . . . . . . . . . . . . . . . . . . .
4. Partial loss of two or more fingers anellor toes, . . . . . . . .
LIMITATIONS & EXCLUSIONS
. PLAN n
$ 700
350
600
300
500
250
400
200
100
50
1,000
250
500
200
500
200
500
PIAN I
$350.
175
iji300~~~-;::~?:~'
-._~150 '.',"-:1,
.. ...-.......---..- ~.'
----~---,:, ._,.
::250
...: 125
"250
500
200
500
200
500
100 100
300 300
100 100
25 25
100 100
200 200
250 250
500 500
50 50
100 100
We will not pay benefits for death, dismemberment or injury which is caused by or occurs as a result of your:
. Being exposed to war or any act of war, declared or
undeclared; or service in the armed forces
. Driving any taxi or intrastate or interstate long-distance
vehicle for wage, compensation or profit
. Mountaineering, parachuting or hang gliding
'\
/ . Participation in any sport for payor profit; or racing any
type vehicle
. Participation in any form of flight aviation other than as a
fare-paying passenger on a licenseellpassenger-carrying
aircraft
. Committing or attempting to commit suicide whether sane
or insane
. Participating in or attempting to participate in any illegal
activity that is classified as a felony, whether charged or not
. Disease, bodily infirmity, or any other cause other than
accident
. Hospitalization that begins before the policy effective date
(The term "hospital" does not include convalescent, nurs-
ing or custodial facilities.)
. Intentionally self. inflicted injury or wounds
. Being under the influence of narcotics, unless administered
on the advice of a physician
FINANCIAL
;"
'" "-':GAPS
I
MAJOR~ICAL
COLONIAL
Pays HospitallDoctors
Pays Cash to You
To help cover
out"of"pocket expenses.
Loss of wages/salary
Oeductibles/coinsurance
Travel expenses for treannent
Lodging and meals
To cover direct costs.
Hospital charges
, Surgeon fees
Physician fees
Medication costs
Colonial plans share these important features:
".. Coverage is available for spouse and children.
You receive benefits paid directly to you unless otherwise specified.
Coverage is affordable.
.. You can continue coverage when you retire or change jobs.
You receive benefits regardless of other coverage.
-- No deductibles.
Prompt claims se1Vic~.
SIn
Colonial. plans provide Culditional coverage. They do not
: replace)'OUr major medical plan. You should not
c1wose between one or the. other~
COLONIAL'
UFE & ACCIDENT INSURANCE COMPANY
._j .
@ 1991 Colonial Life & Accident Insurance Company 43822
Answers to Your
Questions About
This Plan ~'r r
, .< ~
~,Q. Who receives.my
,:,;, benefit payment!' '
.~~ .~~,:;:~kYourbe~efitS~ ,;:
.:::~~ ;~"', '\:;:be'paid directly to -"0:['
:<' :i'UDleSs'you ask {oi>~',~'-
': .:.,3:them to be paid else;;"
'~.. ':,~- "E;:w.h;~~:Ir.'-L<:<.L:'~,{~..\
,,_ , .' "J~. _ _~_
{Jt,:~;E,5~~Sfh;:~5~~:.:
]~, ;~, . ':~':;;:;-rance?'. ., ~>,,:;:'.:~:~':',':':_~'i :;<;'-~"
- '
;' ":',A.No~ Your benefits,'
, ":'';:will be paid regardlesS
'~-::~.;::::,~{ any other insurance
, you may have, includ-
ing workers' compen-
sation, group hospital-
ization and social
security.
\
)
Q. Is there a limit on
the number of claims?
A. No. You are
covered for accidental
injuries that occur
after the effective date
of your policy with no
limit on the number
of claims. You will be
covered 24 hours a
day, 365 days a year
except as noted.
Q. Can my coverage be
continued if I change
jobs or retire?
'A. Yes, your coverage
can continue if you',;
'. 'change jobs or retire.
Your Colonial Accident Protection Plan will pay you benefits
when you suffer these injuries or require these services as a
result of a covered accident which occurs on or off-the-job
even if you continue working:
Injuries
Bums
(based on size and degree)
$600
Lacerations
(which require stitches)
over 5 inches $200
2 to 5 inches $100
up to 2 inches $ 50
Services
Ambulance
Injuries Requiring Surgery
T endons/Ligaments Ruptured Disc
Multiple $600 1st policy year $100
Single $400 Thereafter $400
$25
$25
$50
Appliances
Blood/Plasma
Eye Injuries $100
(requiring surgery
with anesthesia)
Torn Knee Cartilage
1st policy year $100
Thereafter $400
Emergency Treatment
Guarantees a minimum payment for injuries received
in any covered accident. Payable only when other
benefits are not paid. ' $25 '
Complete Dislocations
Hip
Knee
Shoulder
Foot, Ankle
Hand
Lower Jaw
Wrist
Elbow
One Finger , Toe
Complete Fractures
Hip, Thigh $1,500
Vertebrae 1,350 '
Pelvis 1,200
Skull (depressed) 1 ,125
Leg 900
Foot, Ankle, Knee Cap 750
Forearm, Hand, Wrist 750
Lower Jaw 600
Shoulder Blade, Collar Bone 600
Upper Arm. Upper Jaw 525
Skull (simple) 525
Facial Bones 450
Vertebral Processes 300
Coccyx. Rib, Finger, Toe 120
These are the highlights of your benefits. Please see the Outline of Coverage and
your policy for complete details.
$1,350
975
675-750
600
525
450
375
300
120
. .:
/
Medical Fees for Each Covered Accident
Extra benefits for injuries which occur up to
Pays up to a total of $150 for each covered accident. This includes benefits for doctors'
charges (including, but not limited to, chiropractors, osteopaths and podiatrists' charges),
X-ray charges and up to $50 for emergency room fees. It also includes benefits for dentists'
charges for the treatment of injuries to natural teeth.
If you receive treatment in a facility where no charges are made. we will pay $25 for each
day you are treated in this facility up to $150 for each covered accident.
$150
Benefits for Each Covered Injury or Sickness
Hospital Admission
We will pay this benefit when you are admitted to a
hospital and confined at least overnight because of
injuries received in a covered accident or sickness.
$250
Hospital Confinement
We will pay this benefit for up to 3 months
beginning the first day of confinement in a hospital
because of injuries received in a covered accident or
sickness.
$1,200/month
($40/day)
Accidental Death and Dismemberment Benefits
Loss of a Finger/Toe
Loss of a Hand/Foot or Sight of an Eye
I Single Loss
Double Loss
$ 250
$ 2,500
$ 5,000
Accidental Death
$ 5,000
Accidental Death Caused by Car Accidents
Accidental Death While Traveling
death which occurs while you are paying a fare and riding
anywhere in the world on a plane, train, boat or ship
We will pay you on~the~job benefits if you are injured in a covered accident while you are working
for payor benefits.
$10,000
$15,000
Plan
Monthly Premium $
Premium per Pay Period $
PLUS - Optional Life Insurance to Meet Income Needs Faced by Your Family If You Die
~."'.....,~ 6 "J1
I: CltbnsASo.I..... !Ii....... IeaII C1.ADCDIlAPT
II ~~~ .. . f2!;,~ N2 C 00460~
Z-No__o....
*Immediate Payment of $
\lOCl.,.,..oo.WI_
s XYYY no
,
i
I
rOrME'fJlIEilSUlIlPI
c...... Wit" Acno6IM I--.C.....,
c-.__c-
DOLU..
C;IJ;r-'1lit - .
~
"oa..'a~1" ~:a5Jq00.17?f:S01~ qll'" SAP1'LE CHECk
*Simplified Issue
*Family Protection Available
Plan
Monthly Premium $
Premium per Pay Period $
22263-3-MN
Colonial Life & Accident Insurance Company, Columbia. South Carolina 29202
OUTIINE OF COVERAGE - Comp
(Applicable to Policy Form LPAS.MN and Life Policy Form
MONTIlL Y PREMIUM
PLAN
, '
Accident/Sickness Premium $
/
Total Monthly Premium $
Read your policy carefuIly. This outline provides a brief description
of the important features of your policy. This is nor an insurance
contract and only the actual policy provisions will control. The policy
sets forth in detail the rights and obligations of both you and us, It is.
therefore. important that you READ YOUR POLlCY
CAREFULLY.
Renewability: Your policy is guaranteed renewable. Your premium
can be changed only if we change it on all policies of this kind in force in
the state where you live,
Accident and Sickness Coverage. Your policy is designed to provide
coverage for certain losses which result from covered accidents and
sicknesses subjecr to any limitations in your policy. It does not provide
coverage for basic hospital. basic medical-surgical or major medical
expenses.
SPECIFIED INJURY/SERVICE BENEFITS
We will pay these benefits if you receive injuries in a covered accident
which require treatment by a docror within 60 days and repair through
surgery within 1 year afrer the accident:
Ruptured Disc During first policy year $100
Thereafrer $400
During first policy year $100
Thereafter $400
We will pay these benefits if you receive injuries in a covered accident
which require treatment by a doctor or services within 90 days after the
accident:
Tendons and Ligaments which require repair through surgery
repair of 1 $400
I repair of all if more than 1 $600
If you receive a fractUre or dislocation as the result of the same accident.
we will pay only the largest amount.
Eye Injuries which require repair through surgery with
anesthesia
Fractures (Broken Bones)
Tom Knee Cartilage
,
$100
closed reduction $120 10 $ 1.500
open reduction $180 10 $ 2,250
chip fractures $ 12 10 $ 150
Dislocations (Separated Joints) which require corrections
closed reduction with anesthesia $120 10 $ 1,350
open reduction $180 10 $ 2,025
closed reduction. no anesthesia $ 30 10 $337.50
incomplete dislocation requiring
closed reduction $ 3010 $337.50
If you receive more than 1 fractUre, more than 1 dislocation or a
fractUre and a dislocation in the same accident. we will pay no more
than 1!-2 times the amQ,unt for the bone or joint involved which has the
highest benefit amount.
Appliances to help you move around $25
Ambulance for transportation to a hospital $25
Blood and Plasma $50
We will pay these benefits if you receive injuries in a covered accident
which require treatment by a doctor within 72 hours after the accident.
Lacerations which require stitches up to 2 inches $ 50
2 to 5 inches $100
over 5 inches $200
Only 1 amount will be paid for all lacerations received in anyone
, accident. If you lose a finger/toe as the result of the same accident, we
.I will only pay the largest amount.
Burns which are 2nd degree and cover at least 36% of the body surface
or 3rd degree and cover at least 9 square inches of the body
surface $600
We will pay this benefit if you receive injuries in a covered accident which
Form LPASO-MN
Ufe Premium $
TOTAL PREMIUM PER PAY PERIOD $
require treattnent by a doctor within 60 days after the accident, and you
are not eligible for any other benefit in your policy:
Emergency Treatment $25
ADDITIONAL BENEFITS FOR ACCIDENTAL INJURIES
Medical Fees up to $150
for doctors' charges, X-ray charges and emergency room fees (up to
$50) for the treattnent ofinjuries received in acovered accident up to 1
year after the accident if they are first treated within 60 days after the
accident.
Hospital Confinement
$1,200/mo.
($40/day)
for confinement in a hospital because of injuries received in a covered
accident or sickness for up to 3 months.
A hospital does not include a nursing home. convalescent home.
extended care or similar facilities. We will not pay benefits for more
than I hospital confinement at a time.
Hospital Admission $250
for admission to a hospital if you are confined at least overnight because
of injuries received in a covered accident or sickness.
If you are not confined ro a hospital for a full month. we will pay the
appropriate benefits on a daily basis. A month is 30 days. The daily
amount is !l30th of the monthly amount.
We will pay these benefits if you receive injuries in a covered accident
which cause the following within 90 days after the accidenr:
Los. of a FingerlT oe loss of I $250
loss of more than I $500
If you also lose a hand/foot as the result of the same accident. we will
pay only the largest amount.
Los. of a Hand/Foot or single loss $ 2.500
Sight of an Eye double loss $ 5.000
If you also die as the result of the same accident. we will pay only the
largest amount.
Accidental Death
Accidental Death Caused by Car Accidents
Accidental Death While Traveling
We will pay only one of the death benefits.
WHAT IS NOT COVERED BY THIS POLICY
$ 5,000
$10,000
$15.000
We will not pay benefits for an injury or a sickness which is caused by
or occurs as the result of: (1) your involvement in any period of armed
conflict; (2) your riding in or driving any motor-driven vehicle in a
pre-arranged or organized race. stunt show or speed test; (3) your
operating, learning to operate. serving as a crew member afar jumping
from any aircraft. including those which are not motor-driven; ( 4 ) your
traveling more than 40 miles outside the territorial limits of the United
Scates, Canada. Mexico. Puerto Rico. the Bahama Islands, the Virgin
Islands, Bermuda or Jamaica. except as provided for in the Accidental
Death While Traveling benefit; (5) your participating or attempting to
participate in a felony or wotking at an illegal job; (6) your committing
or crying to commit suicide or your injuring yourself intentionally.
whether you are sane or not; (7) your having a mental or nervous
disorder or disease; (8) your having a sickness or physical condition
which was created or for which you received advice within twelve
months before the effective date of this policy.
We will pay benefits for any sickness or physical condition twelve
months after the effective date of this policy unless it is excluded by
name or specific description in this policy.
LIFE COVERAGE
This life coverage provides immediate financial relief for your benefi-
ciary. Should death occur as a result of suicide within the first two years
of your policy, we are responsible only for the return of premiums paid.
2226J.J.MN
"
Answers to Your
Questions About
. ',This Plan . ~;~
, -
. .- -. - .".-.." ~ ,
. . .. --~'>" .";":::-~,~~:~"'7~~~.i./,,~~~.""""~'~"
,,':'::'Q. Who receives my .
"!benefit payment!'<..,
,~,-,:.A.:YoUr benefits "iilli,
. :;;: be'pl'lid directly to you '
':Un1ess you ask for <'~.~
. .~:: them to, be paid else~ '
. "', "where~ ': '-,:;.~;,>"~:_ ,',' :
,~,:-::':.: :::7":.:~;.... ". :-_~_'-'. ~,...::_~- :O,i':'- '--,..,." "-~.'-' .
_.~ '", .. "'" ....--- ," -,.-.. '-
.~'. '~':-:-~'t--.:~".;: _;,~~ .-..1',:;;;,'~',;''-
-~.;..Q'-Are theSe benefits :,
'}}:;":liffectedby'otherIDsu;::
- :_~'~_;~;~(ran~? .j-;t~~~.:.:. ~~--:'_:;f{j:'::::-~.:',7>:
,,:iA. No; Your benefits:-
',>;..':Will be paid regardless
., ':,~'::. of any other insurance
~you may have, includ-
ing workers' compen-
sation, group hospital-
wtion and social
security.
Q. Is there a limit on
the number of claims?
A. No. You are
covered for accidental
injuries that occur
after the effective date
of your policy with no
limit on the number
of claims. You will be
covered 24 hours a
day, 365 days a year
except as noted.
Q. Can my coverage be
continued if I change
jobs or retire!
A. Yes, your coverage
can continue if you
change jobs or retire.
Your Colonial Accident Protection Plan will pay you benefits
when you suffer these injuries or require these services as a
result of a covered accident which occurs on or off-the-job
even if you continue working:
~~ Inj~:~s
. ,\ ~ (based on size and degree)
, . \ J
..;.) ,
><,\~l. '. i
r\] ~;:j
:; t~ ..:'~'lr1
~ .~_. _....--.-.......
$600
Lacerations
(which require stitches)
over 5 inches
2 to 5 inches
up to 2 inches
$200
$100
$ 50
Services
Ambulance
Appliances
Blood/Plasma
Injuries Requiring Surgery
Tendons/Ligaments Ruptured Disc
Multiple $600 1st policy year $100
Single $400 Thereafter $400
Eye Injuries $100 Tom Knee Cartilage
(requiring surgery 1st policy year $100
with anesthesia) Thereafter $400
$25
$25
$50
Emergency Treatment
Guarantees a minimum payment for injuries received
in any covered accident. Payable only when other
benefits are not paid. $25
Complete Dislocations
Hip
Knee
Shoulder
Foot, Ankle
Hand
Lower Jaw
Wrist
Elbow
One Finger. Toe
Complete Fractures
Hip, Thigh $1,500
Vertebrae 1,350
Pelvis 1,200
Skull (depressed) 1,125
Leg 900
Foot, Ankle, Knee Cap 750
Forearm, Hand, Wrist 750
Lower Jaw 600
Shoulder Blade, Collar Bone 600
Upper Arm, Upper Jaw 525
Skull (simple) 525
Facial Bones 450
Vertebral Processes 300
Coccyx, Rib, Finger, Toe 120
These are the highlights of your benefits. Please see the Outline of Coverage and
your policy for complete details.
$1,350
975
675-750
600
525
450
375
300
120
Medical Fees for Each Covered Accident
Extra benefits for injuries which occur up to $250
\ Pays up to a total of $250 for each covered accident. This includes benefits for doctors'
charges (including, but not limited to, chiropractors, osteopaths and podiatrists' charges),
X-ray charges and up to $50 for emergency room fees. It also includes benefits for dentists'
charges for the treatment of injuries to natural teeth.
If you receive treatment in a facility where no charges are made, we will pay $25 for each
day you are treated in this facility up to $250 for each covered accident.
Benefits for Each Covered Injury or Sickness
Hospital Admission
We will pay this benefit when you are admitted to a
hospital and confined at least overnight because of
injuries received in a covered accident or sickness.
$300
Hospital Confinement
We will pay this benefit for up to 3 months
beginning the first day of confinement in a hospital
because of injuries received in a covered accident or
sickness.
$1,200/month
($40/day)
Accidental Death and Dismemberment Benefits
Loss of a Finger/Toe
, Loss of a Hand/Foot or Sight of an Eye
Single Loss
Double Loss
$ 250
$ 5,000
$10,000
Accidental Death
$10,000
Accidental Death Caused by Car Accidents
Accidental Death While Traveling
death which occurs while you are paying a fare and riding
anywhere in the world on a plane, train, boat or ship
We will pay you on~the~job benefits if you are injured in a covered accident while you are working
. for payor benefits.
$20,000
$30,000
Plan
Monthly Premium $
Premium per Pay Period $
PLUS - Optional Life Insurance to Meet Income Needs Faced by Your Family If You Die
Q."""DlWT ....
.....
_ ' fOL~ N2 C 004601
~"".kI~
au... SHIIMnI :-l.ltOQI Bull
QlfSOUl'11C~
COl.uMaA. SOUTH CMCllJN.&
It,
TUTHI':
UICDEtlOr.
'."f.. 1..ooMf_._lOliUOIKU'T."""-I...... "..._...LO'OfI_.......
loMNo__D.lf
.Immediate Payment of $
~OIO.vTI.ONII Yf,""
s xxxx.xx
oot....... .
c-:tJ;t-jT I1f . '. :
~.
"OO"'bO~1" "':OSlQ003111:S03. Q3i!&" SAHPLE CHECI(
.Simplified Issue
I
ro1'W4E~"
c....... UI.. ,,"*- 1_ <.:.....,
c- _c-
.Family Protection Available
Plan
Monthly Premium $
Premium per Pay Period $
22262-3-MN
Colonial Life & Accident Insurance Company, Columbia, South Carolina 29202
OUTLINE OF COVERAGE - Business & Professional
(Applicable to Policy Form LPAS.MN and Life Policy Form
MONTHLY PREMIUM
PLAN
Accident/Sickness Premium $
Total Monthly Premium $
Read your policy carefully. This outline provides a brief description
of the important features of your policy, This is not an insurance
contract and only the actual policy provisions will control. The policy
sets forth in detail the rights and obligations of both you and us, It is,
therefore, important that you READ YOUR POLICY
CAREFULLY.
,
Renewability: Your policy is guaranteed renewable. Your premium
can be changed only if we change it on all policies of this kind in force in
the state where you live,
Accident and Sickness Coverage. Y our policy is designed to provide
coverage for certain losses which result from covered accidents and
sicknesses subject to any limitations in your policy. It does not provide
coverage for basic hospital, basic medical-surgical or major medical,
expenses.
SPECIFIED INJURY/SERVICE BENEFITS
We will pay these benefits if you receive injuries in a covered accident
which require treatment by a doccor within 60 days and repair through
surgery within 1 year after the accidene:
Ruptured Disc During first policy year $100
Thereafter $400
During first policy year $100
Thereafter $400
We will pay these benefits if you receive injuries in a covered accident
which require treatment by a doccor or services within 90 days after the
accidene:
Tendons and Ligaments which require repair through surgery
repair of 1 $400
repair of all if more than 1 $600
If you receive a fracture or dislocation as the result of the same accident,
we will pay only the largest amount.
Eye Injuries which require repair through surgery with
anesthesia
Tom Knee Cartilage
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$100
closed reduction $120 to $ 1,500
open reduction $180 to $ 2,250
chip fractures $ 12 to $ 150
Dislocations (Separated Joints) which require corrections
closed. reduction with anesthesia $120 to $ 1,350
open reduction $180 to $ 2,025
closed reduction. no anesthesia $ 30 to $337.50
incomplete dislocation requiring
closed reduction $ 30 to $337.50
If you receive more than 1 fracture, more than I dislocation or a
fracture and a dislocation in the same accident. we will pay no more
than 1\1 times the amount for the bone or joint involved which has the
highest benefit amount.
Appliances to help you move around
Ambulance for transportation to a hospital
Blood and Plasma
Fractures (Broken Bones)
We will pay these benefits if you receive injuries in a covered accident
which require treatment by a doccor within 72 hours after the accident.
Lacerations which require stitches up to 2 inches $ 50
Zeo 5 inches $100
over 5 inches $200
Only 1 amount will be paid for all Iacerations received in anyone
'~ accident. If you lose a finger/toe as the result of the same accident, we
/ will only pay the largest amount.
Bums which are 2nd degree and cover at least36% of the body surface
or 3rd degree and cover at least 9 square inches of the body
surface $600
We will pay this benefit if you receive injuries in a cover~ accident which
Fonn LPASO-MN
Life Premium $
TOTAL PREMIUM PER PAY PERIOD $
require treatment by a doctor within 60 days after the accident, and you
are not eligible for any other benefit in your policy:
Emergency Treatment $25
ADDITIONAL BENEFITS FOR ACCIDENTAL INJURIES
Medical Fees up to $250
for doccors' charges, X-ray charges and emergency room fees (up to
$50) for the treatment of injuries received in a covered accident up to 1
year afrer the accident if they are first treated within 60 days after the
accident.
Hospital Confinement
$1,200/mo.
($40/day)
for confinement in a hospital because of injuries received in a covered
accident or sickness for up to 3 months.
A hospital does not include a nursing home, convalescent home.
extended care or similar facilities. We will not pay benefits for more
than 1 hospital confinement at a time.
Hospital Admission $300
for admission to a hospital if you are confined at least overnight because
of injuries received in a covered accident or sickness.
If you are not confined to a hospital for a full month, we will pay the
appropriate benefits on a daily basis. A month is 30 days. The daily
amount is 1/30th of the monthly amount.
We will pay these benefits if you receive injuries in a covered accident
which cause the following within 90 days after the accidene:
Loss of a Fingerrr oe loss of 1 $250
loss of more than 1 $500
If you also lose a hand/foot as the result of the same accident, we will
pay only the largest amount.
Loss of a Hand/Foot or single loss $ 5,000
Sight of an Eye double loss $10,000
If you aIso die as the result of the same accident, we will pay only the
largest amount.
Accidental Death
Accidental Death Caused by Car Accidents
Accidental Death While Traveling
We will pay only one of the death benefits.
WHAT IS NOT COVERED BY THIS POLICY
$10,000
$20,000
$30,000
$25
$25
$50
We will not pay benefits for an injury or a sickness which is caused by
or occurs as the result of: ( 1) your involvement in any period of armed
conflict; (2) your riding in or driving any motor-driven vehicle in a
pte-arranged or organized race, stunt show or speed test; (3) your
operating,learning to operare, serving as a crew member of or jumping
from any aircraft, including those which are not motor-driven; (4) your
traveling more than 40 miles outside the territorial limits of the United
States, Canada, Mexico, Puerto Rico, the Bahama Islands, the Virgin
Islands, Bermuda or Jamaica, except as provided for in the Accidental
Death While Traveling benefic; (5) your participating or attempting to
participate in a felony or working at an illegal job; (6) your committing
or crying to commit suicide or your injuring yourself intentionally,
whether you are sane or not; (7) your having a mental or nervous
disorder or disease; (8) your having a sickness or physical condition
which was treated or for which you received advice within twelve
months before the effective date of this policy.
We will pay benefits for any sickness Ot physical condition twelve
months afrer the effective date of this policy unless it is excluded by
name or specific description in this policy.
LIFE COVERAGE
This life coverage provides immediate financial relief for your benefi-
ciary. Should death occur as a result of suicide within the first two years
of your policy, we are responsible only for the rerum of premiums paid,
ZZZ61-J-MN
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MONTHLY WEEKLY
/l-c.c.. a4.1-(. F7 16.40 ................ 3.79
,1Ic..c- Z... (,.0 n-<..r F8 17.00 ................ 3.92
FI0 18.20 ................ 4.20 --"
A-A D7 17.10 ................ 3.95
MNOl t+p Da 17.75 ................ 4.10
DI0 19.10 . . .,1- . . . . . . . . . . . . 4.41
510 20.75 ................ 4.79
;Ice (j"":.E F7 23.05 ................ 5.32 .
..~ . ./,vc.oPO( Fa 24.00 ................ 5.54
,~ .~ -
FI0 25.95 ....-............ 5.99
A-A D7 25.95 ................ 5.99
~!-.. MN02 6'"7' D8 27.20 ................ 6.28
I) DI0 29.65 ................ 6.84'
510 36.55 ................ 8.43
/lct:.. ~A.r€ F7 27.55 6.36
................
I'It: c 7~c.o""P. Fa 28.50 ................ 6.58
FI0 30.45 ................ 7.03
A-A D7 32 . 25 . . . . . . . . . . . . . ... . 7.44
MN03 j;~ D8 33.60 ................ 7.75
DI0 36.30 ................ 8.38
510 42.95 ................ 9.91
.II<<.. .J. S,c. J;; N<S! L!aJ~ F7 24.65 .'f' . . . . . . . . . . . . . . 5.69'
, Fa 25.25 5.83
,-c..c.. (),.;~ ................
.:7,(J'-'Y 1 0 26.45 ................ 6.10
C/ A/S-A D7 25.35 ................ 5.85
MN04 6H:> D8 26.00 ................. 6.00
-- DI0 27.35 6.31
................
510 29.00 . . . . . . . . . . . . . . . . 6.69
Jicc. + .:, '-I:::. t:rl:'c F7 29.85 ................ 6.89
, . l. - Fa 30.80 ................ 7.11
':-.: :. '~'.J.;~ .,b . ~~cc.'I'f< 32.75 7.56
' / FIO . . . . . . . . . . . . . . . .
, A/S-A D7 32.75 ................ 7.56
, MN05 6.n-p DB 34.00 ................ 7.85
DI0 36.45 ................ 8.41
510 43.35 ................ 10.00
4c.c. "f j /,:-< .JJA-!c F7 34.80 ................ 8.03
4rt:.. '0""'1 F8 35:75 ................ 8.25
:I.v(!c,I>"-c FI0 37.70 . . ... . . . . . . . . . . . . 8.70
A/5-A D7 39.50 ................ 9.12
MN06 X" D8 40.85 ................ 9.43
~ DI0 43.55 ................ 10.05
510 56.50 ................ 13.04
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MONTHLY WEEKLY
Ih:.- .j. .s/c.~ ~~ F7 42.80 ................ 9.88
/- " Z'AJ~ F8 45.95 ................ 10. 60 ..
FI0 53.00 ................ 12.23
A/S-A/S D7 42.80 ................ 9.88
MN04 D8 46.70 ................ 10.78
DIO 53.10 ................ 12.25
S10 54.75 ................ 12.63
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CCI;.,r' /KC 'l-r~t.k. eo# - F7 48.00 ................ 11. 08
'. _c F8 51. 50 ................ 11. 88
.7AJC()Ioo~FI0 58.50 ................ 13.50
A/s-A/s D7 50.90 ................ 11.75
MNO~ D8 54.70 ................ 12.62
DI0 58.20 ................ 13.43
S10 69.10 ................ 15.95
-0
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4~ .n;d:: il",:c F7
/, ZolVcc"..~F8
FI0
A/s-A/S D7
MN06 D8
DI0
S10
55.50
59.35
67.05
60.20
64.45
72.90
85.85
................
12.81
13.70
15.47
13.89
14.87
16.82
19.81
. . . . . . . . .. . . . . . . .
................
................
................
................
................
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14 90
19 65
................
................
12.55
18.05
.90
.17
2.25
3.29
5.16
7.89
4.48
7.19
................
NOTE::::::
HI-WEEKLY DEDUCTIONS - MULTIPLY WEEKLY X 2
r
TWICE A MONTH DEDUCTIONS - DIVIDE MONTHLY
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.thin your reach
PREMIUM CONVERSION PLAN
Your spendable income
; increases, making
your benefits
1T1OTe affordable.
Your Benefits Are Enhanced
Take advantage of an option that can make
your benefits more affordable-a premium
conversion plan. You can enhance your
benefits package by participating in this
valuable option, available through your
employer's flexible benefits plan. By taking
time to learn more about this plan, you can
make the most of your benefit choices.
The History
Premium conversion plans are possible
because of Internal Revenue Code Section
125. The United States Congress created
Code Section 125 as part of the Revenue Act
of 1978 to make benetits more affordable for
employees. Y ouremployer has asked Colonial
Life & Accident Insurance Company to
implement this plan and present it to you.
How It Works
When you participate in a premium conver-
sion plan, you choose qualified insurance
coverages that meet your needs and pay the
premiums with pretax dollars. Pretax dollars
are subtracted from your gross earnings before
taxes are taken out. When you pay qualified
insurance premiums before taxes, you lower
your taxable income so you pay less in taxes.
Y ourspendable income increases, making your
benetIts more affordable.
A Personal Example
Let's look at an example using John's weekly
salary of $250. Through paFoIl deduction, he
currently pays $20 a week to cover his family
under a major medical plan.
Here's what John's paycheck looks like with-
out a premium conversion plan:
John'~P;:y~h~k"'-c--. -.-.-------
Employee Starm: Married, three fed. exemptions
Weekly Salary: $250
Gross Pay
Pretax Reduction
RCA, Fed. &
State Taxes
Payroll Deduction
Spendable Income
$250.00
-0-
-33.27
-20.00
196.73
With premium conversion. John can pay his
major medicall'remium before taxes are taken
out. Here's how this plan makes John's benefits
more affordable:
Premium Conversion Plan lllustration
Employee Status: Married, three fed. exemptions
Weekly Salary: $250
Qualified Benefits: Major Medical/$20
Without
Prem.Conv.
With
Premo Cony.
Gross Pay
Pretax Reduction
Taxable Gross
RCA, Fed. &
StateT axes
Payroll Deduction
$250.00
-0-
250.00
-33.27
-20.00
$250.00
-20.00
230.00
-27.54
Spendable Income $196.73
$202.46
John reduced his pretax income by paying his
premiums before taxes were deducted from his
paycheck. Because John's taxable income is
less, his taxes are lower-$27.54 instead of
$33.27 Each week, John's spendable income
increases by $5.73. By the end of the year,
John's spendable income increases by $297.96.
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You'll be amated
at the benefit choices
)ithin :YOUT Teach.
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Plan Details
To comply with IRS requirements, you may
only make a change in your election at the
beginning of each plan year. This means you
may not make a change in your elections after
the open enrollment period unless you experi-
ence a family status change. The IRS gives the
following as examples of family status changes:
... Marriage or divorce.
... Death of a spouse or dependent.
... Birth or adoption of a child.
... Termination or commencement of
employment by employee's spouse.
... Employee or employee's spouse changing
from part-time co full-rime employment or
from full-rime co part-rime employment.
... Employee or spouse taking an unpaid le-ave
of absence.
... Significant change in the health coverage
of the employee or the employee's spouse
attributable co the spouse's employment.
Understanding The Choices
With this program, you have choices and
opportunities you've never had before. It is
important co understand these choices as com-
pletely as possible. Reading this newslerter is
the first step. Attending an individual plan-
ning session is the next step.
During an individual planning session, your
Colonial Representative will answer questions
and estimate your ta"( savings using a premium
conversion plan. After you have enrolled, you
will receive a confirmation of your decisions.
Adding Additional Benefits
During enrollment, you can cake advantage of
your increased spendable income by adding
additional voluntaxy benefits that meet your
needs. Many of Colonial's coverages qualify for
your employer's premium conversion plan.
For example, if John chooses to purchase
Colonial coverage in addition to his major
medical plan, here's how it would affect his
paycheck:
C';'-. ,"~,,~"',--_ ~~"-:~.:.__~:.~;;_~~~.--, -.~._:_~-, .;~~- ~"'t~--,. -:77~~
. Preini~ COiiverSi~:PlaJl mustratiim'c~~c1
':EmPloy~ ScitUS:.Marrled;tnreered~rnI:T;o1
-; 'ex- ~ -em" -- ..~;....,'". :<-<~:,;-.~.."~,";" ; f- ,~,?;;,~.; :c....' ~~t_:.'_.::;.;"":, -.; ;'b""'!:. -~
.' PUU.l..L3 .."..# .,.,...~ ,...f ......."....,i'....."'....<- .J.... ._""'-'.-.,,0/....,. ,t
-Weekly-S~$i5-Qr-';.'r~:;'r4:-;f;>2<: c j
:~ifi~&#itE~(~j;;;'M~mO;
{i4fiit~~.j
~..=.~t..~; . :~~:=c.:~-_..~.>.:~c::: .
" __:..-;'-:-"':0>:'" ._ I.,',~~....'," '::';_.'':''' ~:. .' ~ -
'~':..' ~', -,_. >t: .."'"..::....., ,_ _~. _ ","' . .~,' .-
GrossPay ~o:.. $250.00 $250.00
Pretax Reduction ,'-20.00 -30.00
Taxable Gross 230,00 220.00
FICA, Fed. &
State Taxes -27,54
Payroll Deduction -10.00
Spendable Income $192.46
-24.68
-0-
$195.32
John's taxes are again lowered-$24.68 versus
$27.54. Even though John has purchased
additional Colonial coverage, his spendable
income is increased by $2.86 each week.
Through premium conversion, John's benefits
are more atfordable.
You can tailor your own benefitS package by
choosing affordable Colonial coverages you
want and need.
The Next Step
During enrollment, your Colonial Representa-
tive will explain how a premium conversion
plan can work for you. Then you sign an
election form indicating your decision whether
or not to participate. When the plan year
begins, your paycheck will reflect your partici-
pation in the plan.
Take the time to meet with your Colonial
Representative. You'll be amazed at the benefit
choices within your reach.
e 1992 Colonial Lite & AcciJen, Insurance c,mrany 4324i.1
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PHASED TMPT.EMENTATION
The success of any flexible benefits plan can be directly attributed to how well the plan is communicated
to employees and how well they understand the benefits in order to make "infonned" decisions. For this
reason, Colonial often helps employers implement their plan in phases in order to minimize the
complexity.
Phase I is the establishment of a premium only plan (commonly referred to as pop or premium
conversion plan), whereby only eligible premiums such as medical, dental, vision and voluntary
payroll-deducted products will be included in the menu of benefits. Colonial will provide the
communications expertise in tenns of both knowledgeable representatives and effective materials.
In addition, we support your plan through on-going service including IRS Fonn 5500 assistance,
flexibility to handle multiple payroll frequencies, state-of-the-art Qaims and Oient Services
assistance, and membership in organizations dedicated to making its members the best infonned
and most highly competent in the employee benefits field.
Phase IT involves the expansion of the plan to include flexible spending accounts (medical
reimbursement and dependent care assistance). When you decide to expand the plan to include one
or both of these flexible spending accounts, Colonial will continue to provide communications and
implementation support at no cost to you or your employees. BenefitAmerica will provide the
administrative services to support this phase of the plan. These services include efficient handling
of spending account deductions and reimbursements, providing detailed reports to you and your
employees, completion of IRS Fonn 5500, and providing discrimination testing. The fees for
administrative services will be negotiated once a decision has been made to expand the plan.
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Although we recommend the "phased" approach, we are fully capable of helping implement both phases
simultaneously.
Providing superior consulting, communications and administrative services: Colonial and
BenefitAmerica. Together, we're ready to work for your organization by successfully implementing a
flexible benefits plan - a plan that provides valuable alternatives to today's employee benefits
programs.
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FEE SCHEDULE
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FOR:
an OF ANDOVER
INITIAL SET-UP FEE (one time):
$ 0.00 (if employer has at least
75 eligible employees)
$250.00 (if employer has less than
75 eligible employees)
CONSULTING FEES:
no charge
COMMUNICATIONS AND ENROLLMENT FEES:
Plan Documents
Enrollment Support Materials
Benefits Counselors
no charge
no charge
no charge
ANNUAL ENROLLMENT FEE:
no charge
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ADMINISTRATIVE (SERVICE) FEES:
Premium Conversion
Dependent Care Reimbursement Account
Medical Reimbursement Account
Maximum Service Fee
$1.50
$2.25
$2.25
$4.00
per participant per month
per participant per month
per participant per month
per participant per month
Minimum Monthly Fee (oer !!Touo):
$25.00
MAILING FEE:
Reimbursement checks mailed to:
(1) employer for distribution
(2) participants' home addresses
no charge
$8.00 per participant oer vear
Many employers pay these fees on behalf of their employees. You may, however, ask your emploYL'es to
pay a portion or the full amount of these fees. If you decide to participate in the Reflex'~program, these
fees cannot be passed on to your employees.
The fees listed above are charged ~ if the administrative services, listed on the previous pages, are
requested of BenefitAmerica. In other words, if only consulting, communications and enrollment
services are required, there will be no fees. However, Colonial's voluntary productls) must still be
made available during the individual enrollment process to eligible employees.
~ ITY ~c.I/'Vc..I'-
RESOLUTION TO THE BOARD OF DIRECTORs-
t!1ff~ r c.. III ~I.;N~/'-
The undersigned ~t of CITY OF ANDOVER hereby certifies that the BQ.-\RD OJ'! .6'lltECTORS
~ ~~
· CITY OF ANDOVER validly adopted the following Resolutions at a meeting of the BOARD OP
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C-ov N.c.t t-
DJRFrTiJRS held on , 19_ and that such Resolutions remain in full force and effect:
~11/ COVtvC-, L- 1"-
WHEREAS, the BO <UID OF DIRJi:CTORS of CITY OF ANDOVER wish to adopt a Cafeteria Plan within
the context of Section 125 of the Internal Revenue Code for the benefit of the Employer's eligible employees.
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NOW, THEREFORE, BE IT RESOLVED, that the BOARD OP DIRI:CTORS hereby adopt the CITY OF
ANDOVER Flexible Benefits Plan (consisting of the Flexible Benefits Plan Document, the Adoption
Agreement, and component Benefit Plans and Policies) effective as of the date specified in the Adoption
Agreement.
~ ~ h,v4-'-<<- ':> 1(l.6'" ;...'l. (:,1 rJ'
RESOLVED FURTHER, that~ of'CITY OF ANDOVER is authorized, without further BO:\IID
CJI.I r'C ( l-
~S approval, to execute the Adoption Agreement, and any related documents or amendments
which may be necessary or appropriate to adopt the Plan or maintain its compliance with applicable federal,
state, and local law .
ATTEST:
;VI r9'i () I'L
-PFe3idcnt:
Date:
~ CtJ";' {!L~I'---
[SEAL]
('QPynght Tonno"Y I. IQQO
*"1n(~' :beg!d-rcqttiremen~for-a-valid-Boar~Directors- Resolution-vary-frollHtate-t<Htate;-'Fhi~cument-is-merel-~gested
...fonn F=h--Emptoyer should consult Wltll IlS own legal wuuod to-ensure-eompliance..MtlLapplicahle law.
:r:-~ d- b .
Deferred Compensation Proposal
3/30/93
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International City Managers Association Retirement Corporation
Proposal is in process.
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Health Insurance Contribution
Approve city contribution of $270.00/month for general
employees, to match contribution in union contract for
works employees.
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3/30/93
city
public
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DIRECT
DEPOSIT
IS HERE!
Folks, we'll be circling for
another hour, so those of you
who need to pick up your paychecks
may disembark now. ,_
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. It's convenient.
. It's dependable.
. It's safe.
. It's flexible.
. It's fast.
. It's for you!
Sign up now
WHEREVER YOU ARE,
YOUR PAY IS
IN YOUR ACCOUNT.
~~5CT
DE~SIT
ITSMONEYINTHEBANJ<! I
sign tip #OJt'~
IT'S MONEY IN THE BANK!
He 643n MKT
"d;:4~~:'c.~~ Y':..',~~~;~~:.t~~n-~F:':.~~~:~j!~.~~i ....._.. ~i.:'.. - . ~. --, -_"';.,...~..'l...,:.-~_~"'1.:~~ ,..> .-....-.:....~.~...".,. /~~..,.~~.{.
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*This is a one-time fee
only.
**Other ACH fees ma
a Iy: See Below:
@';filll$$Q:~'"
'.'.'. .....'......"....$5. ..'...44....'........
::::;;:;:;:;:;;;::::::;:::;:::;;: -, ::.., :. .~::.
................, .
:::;:::::;:::~::::::;::;;;::;:;:'_ ,'_, ,':0::-:.-:.;-.:;::'
.....$. .25....QQ.. ....
.... ,~ ','
.... ,.'.
... '-. ... ...
.... " ,.".
:.~~:;, - -, " ,.... : ,:';'
$60.44
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Weekend Duty Pay - Supervisors
3/30/93
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Approve weekend duty pay for the public works supervisors
of $23.03/hour to match the rate set in the union contract
for the public works employees.
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