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2007-2009 Term Life Agreement ., ~ WE'LL GIVE YOU AN EDGEsM ~=W (- Your group Insurance benefits Proposal for CITY OF SALINA Effective Date January 1,2007 Underwritten by Principal Life Insurance Company Des Moines, IA 50392-0002 www.principal.com Presented by JOHN W BOY ARD Prepared by FRED WATSON Group Non-Medical Sales and Services Thank you for considering group insurance from ~rincipal Life Insurance Company for your employee benefit program. This proposal includes rates and benefit information for: . Group Life Insurance CONYENTIONALLY INSURED RATES Coverage Monthly Employee ' VolumelLives . Monthly Costs Annual Costs Rate Group Term Life $0.19 per $1,000 $17,750,400/516 $3,372.58 $40,470.96 Insurance Dependent Life $3.06 per Family 405 $ I ,239.30 $14,871.60 Insurance - Class 1 Dependent Life $1.84 per Family 6 $11.04 $] 32.48 Insurance - Class 2 Grand Total $4,622.92 $55,475.04 c) A multiple product discount may apply to certain group non-medical insurance products when the group has three or more qualifying coverages from Principal Life. Terminating one or more products could impact discounts being applied at the time of termination. Your sale; representative can provide more information about the discount and which coverages are eligible. The multiple product discount may change or terminate at any time without prior notice, subject to rate guarantee and state requirements. Rate Guarantee for Group Term Life. 3 years unless volume increases/decreases by more than 25% Ratillg Assumptiolls. These rates are based on the following: ;' , . Kansas as ihe contract state. If you have employees located in othe~ states, we may weight the state taxes depending on the number of those employees and apply benefits based on those states' provisions. . An effective date of January 1,2007. Suggest-ed premiums and benefits are only valid 90 days following November 30,2006 and are provided only for illustration purposes. Acceptance of your group, the final premium rates and actual benefits cannot be offered to you until all necessary infonnation about your group has been received and. reviewed by home office underwriters of Principal Life and approved by an officer of Principal Life. Rates will be recalculated based on actual enrollment under the policy. Changes in assumptions, group demographics, policy design and policy effective date may also affect yo~r rates.. Final rates will apply for the period oftime specified in the contract. Rates may increase on renewal in accordance with the terms of the policy. . Th~re ?re limitations, restrictions and exclusions in this p~licy. There iu-e also certain restrictions involving payment of premium, tennination, fraud, eligibility and participation. Final rates are dependent on entering into an insuran~e contract where all limitations, exclusions, and restricti.o.ns are taken into consideration. . As a result of this sale, your broke~ may receive comm!ssion~, administrative service fees, other compensation including non-cash compensation, and bonuses based on factors such as total premium volume and persistency or . profitability of the business. The cost of this compensation may be directly or indirectly reflected in the premium or fee for this product. This compensation is in addition to any compensation your broker may receive from you. Contact your broker for ftll:ther details. c Employee Benefits from Principal Life Insurance Company GP50057-17 09/2006' 09120611078-11 SIC Code: 9121 November 30, 2006 Page 1 ( ( c ~. F/lllJncjal WE'lL GIVE YOU AN EDGEsM Group Coverage During Disability, If an employee becomes totally disabled before age 60, coverage will continue and premium will be waived. The employee must be totally disabled for 9 months or unable to perform at least two activities of daily living for J month before the waiver begins. Coverage continues without premium payment until the employee recovers or turns age 70, whichever occurs first. No benefits will be paid for any disability that results from: willful self-injury or self-destruction, while sane or insane I war or act of war I voluntary participation in an assault, felony, criminal activity, insurrection, or riot. ) POLICY PROVISIONS Eligibility, Coverage is available to all active, full-time employees (except part-time, seasonal, temporary or contract employees) who work at least 30 hours per week. Retiree coverage is available for the Group Term Life coverage only. Employees must be enrolled for Group Term Life.Insurance coverage before it can be offered to their dependents. Dependent coverage is available for an employee;s spouse and unmarried dependent children. Additional eligibility requirements may apply. . Contributions/Participation for Group Term Life and Dependent Life Insurance . 100% participation for all non-contributory coverages . .. 75% participation for all contributory coverages Individual Purchase Rights, Employees who terminate employment may be able to convert to individual policies. Upon coverage termination employers have 31 days after coverage ends to inform their employees of their right to convert to an individual policy without proof of good health. The purchase amount varies depending on the termination situation.' " . Employee Benefits from Principal Life Insurance Company GPS083S-7 02/2006 09120611078-11 Group Term Life Page 3 ~. Fll/JJncial WE'lL GIVE YOU AN EDGEsM Group (-. Your company of choice for employee benefits c ( You can count on the Principal Financial Group'" (The Principal"') for employee benefit solutions. Principal Life Insurance Company, a member of The Principal, offers insurance products with choice and flexibility that allow you to design a benefit program that meets your needs and budget. Tbe result: benefits that help you attract and retain quality employees_ A member of the FORTUNE 500, The Principal is a leader in the life and health insurance industry. Plus, Principal Life consistently receives high financial strength ratings from independent rating agencies. With over 65 years in the employee benefits marketplace, we offer you the expertise of our local benefit professionals, a broad portfolio of competitive group prod~cts and outstanding service. OUR SERVICES eService You can manage benefits 24/7 at OUf secure site on w;ww.principal.com. ~qu can add or 4e1ete Capabilities members, make member changes, order ID cards, search and print booklets, view billing statements, pay premiums and access forms. At the Personal Login, employees can access benefit information, review coverage, check claim status, review Exnlanations of Benefits, access booklets and more. Claim Services You and your employees receive fast, accurate service from a team of registered nurses, certified vocational rehabilitation experts and Social Security specialist who pride themselves in offering individualized assistance to each of our cutomers. . Flexible Spending We offer low-cost FSAs, which allow employees to set aside pre-tax dollars to cover certain health Accounts care and/or dependent care exnenses. Tax savings 00 employee' contributions ma)~ offset nIan costs. Princi~al Health This online service provides educational content, a medical library, health and welIness -information, Newss . and more to helD employees understand health issues and make informed decisions. Beneficiary Beneficiaries have access to two complimentary and con~dential services: a Financial Services Services Hotline and Grief Support Services. The Financial Ser~ices Hotline is staffed with caring professionals who help direct beneficiaries to products and services that will help them plan for their future financial needs. Grief Support Services, provided by Magellan Health Services, connect beneficiaries with professionals who can provide comfort, offer guidance and suggest coping strategies_ Weight Watchers Weight Watchers, America's trusted name in weight loss, has been assisting people with weight loss for over 40 years. Insurance customers can lose weight with help from Weight Watchers programs, including local meetings or an online oro~ram at a reduced rate. Smoking Employees can quit tobacco and lower their risk of heart attack, lung cancer and emphysema with Cessation access to American Center Society's telephone-based t9bacco cessation counseling progr'am, Quitline. Studies have shown this service nearly doubles a smoker's chances of quitting . successfully. Epie Xylitol Employees have access to discounts on Epic Xylitol dental products - including toothpaste, oral Dental Svstem rinse, mints and gums. Xvlitol is a natural sweetener that is very effective in preventing tooth decay. Count on Principal Life for your employee benefit needs. We offer the solutions you're looking for. - Employee Benefits from Principal Life Insurance Company GP54108-3 11/2006 09120611078-11 Page 5 r . \, , .\. ..~.. 210 Mailing Address: I Principal Life I Employer Application for Des Moines, IA 50392-0002 Insurance Company Group Insurance - KS This form is for: ~ new case Requested effective date: January 1, 2007 o amendment Account number Advanced premium received $ Employer Information legal name of company (include dba) City of Salina o corporation 0 partnership 0 sole proprietorship ~ other Municipality Physical address (street) City State 300 W. Ash Street ISalina IKS Mailing address (P.O. box) City State P.O. Box 736 ISalina IKS Contact Telephone number FAX number E-mail address Krystal Norris 1785-309-5710 )785-309-5711 1 krystal.norris@salina.org Nature of business SIC code Federal tax 10 number Number of years in business City government 19121 148-6017228 120+ Have you been insured by Principal life Insurance Company previously? ~ no 0 yes If yes, when and under what name? Has the company been denied credit within the past two years, ever filed for bankruptcy, or is the firm now in the process of (or considering) filing for bankruptcy? ~ no 0 yes (attach an explanation) Complete the following if this coverage replaces other group insurance. Provide a copy of the most recent billing. Note: Include prior carrier information for past three years. Name of Carrier Coverage(s) Hartford Life Insurance ZIP code 167401 ZI P code 167402-0736 Effective Date 01/01/1980 Termination Date 01/01/2007 Employers with Participating Units If employees of any associated business organizations (e.g. parent-subsidiary, brother-sister relationships, affiliated groups, etc.) are to be covered, please list the affiliate or subsidiary beiow. Participating unit is an entity that is an affiliate or subsidiary related to the employer through common control or ownership. Unit name/address/federai tax 10 Nature of business Relationship to company Number of employees ,.Salina Airport Authority ~ include unit 1. '3237.Arnoid Ave. Salina KS Municipal airport 0 exclude unit 12 EIN 48-0727448 o include unit 2. M exclude unit Request for Benefits Medical plan number(s) Illustrated in proposal number o dental I:8J basic tern;Uife PCS plan number Version number o vision 0 short term disability 0 long term disability Options: 0 basic term accidental death and dismemberment I:8J dependent term life o supplemental term life 0 supplemental term accidental death and dismemberment o voluntary term life Options: 0 accidental death and dismemberment 0 accelerated death benefits o medical: Do you want insurance for 0 employees 0 employees and dependents PPO number(s)lname(s) If multiple PPOs are elected, please include a list showing which employees are utilizing each PPO. o network choice. Attach list of which network each employee elects. o benefit choice. Attach list of which benefit each employee elects. . . ., Page 1 of 4 GP 45703-4 08i2004 Waiting Period/Effective Date Provisions (Not all options are available for small employers selecting medical insurance. Initials (employees Waiting Period working the required D 1 month D 3 months number of hours on or before the effective date of new case/new coverage with Principal life): 210 Contact us for more information.) D 6 months [8] Other NONE Note: If you wish all employees to have the same waiting period, the waiting period for initials should be marked the same as futures (employees who have already met the waiting period above do not have to meet it again if continuously working). Waiting Period [8] 1 month D 3 months D 6 months D Other Futures (employees hired the day after the effective date of coverage or later): Employees will be eligible on the: [8] day immediately following the final day of the waiting period D first day of the insurance month (insurance month coincides with premium due date) Employer Contribution Employee Dental % Vision % Short term disability (STDr % Long term disability (L TOr % Basic term life and accidental death and dismemberment % Dependent term life Supplemental term life and acc'ldental death and dismemberment % Voluntary term life % Medical % "If employees contribute to the cost of STD and/or L TO insurance, are these contributions made on a D pre-tax or D post-tax basis? Dependent % % 100 % % % Employee Eligibility NOTE: Airport Authority premiums are paid by Airport Authority, not by City of Salina! Eligible Employees [8] An employee must work at least 30 hours per week to be eligible for insurance. D Other (if agreed to by the home office of Principal Life) Ineligible Employees . An independent contractor (unless required by law) . An employee who works less than the required number of hours per week, or is employed as a temporary or seasonal employee, is not eligible for insurance. Total number of employees (full and pari-time): 616 as of 11/30/06 Describe any class of employees or location(s) excluded from coverage. temporary /seasonal, intermittent Do you have employees or their dependents residing: (check all that apply) D outside the United States? D Hawaii (not eligible for medical insurance) D New York? How many? Complete the following sections for coverages being requested. Life If you are a group with 51 or more employees requesting group term life insurance, do you want insurance for retirees? ~ no 0 yes If yes, 0 your current retirees 0 your future retirees NOTE: We do wish to include coverage for a small group of "grandfathered" retirees, but no new employees may opt to participate upon retirement. Disability If you are requesting short term disability coverage, are there employees working in any of the states listed below (policies offered in these states are Supplemental)? 0 no 0 yes If yes, indicate the number of employees for each state in the box. California Hawaii New Jersey Total number of eligible employees (full and part-time): I 496 as of 11/30/06 New York Rhode Island GP 45703-4 Page 2 of4 0812004 Life/Disability 210 If requesting life or disability insurance, list all employees not actively at work and dependents (if dependent life insurance is requested) in a period of limited activity. David Owen & Dependent Son Joshua (military leave); Glen Godsey, no dependents (military leave) Dental If dental insurance is requested, do you want to insure retirees? 0 no 0 yes If yes, 0 your current retirees 0 your future retirees If you are replacing dental insurance, did your prior dental coverage include benefits for orthodontia treatment? 0 no 0 yes Medical Do you offer medical coverage to your employees through another carrier? 0 no 0 yes, number covered? TEFRA eligibility is defined as employers who employed 20 or more full and/or part-time employees for 20 or more calendar weeks in the current or preceding year. If this requirement is met, the group is TEFRA eligible and Principal Life will pay primary to Medicare. Do you meet the eligibility definition? 0 no 0 yes If you are a group with 51 or more emplo~es requesting medical insurance, do you want insurance for retirees? o no 0 yes If yes, U your current retirees 0 your future retirees MedicallDentalNision COBRA eligibility is defined as employers who employed 20 or more full and/or part-time employees on at least 50% of the working days in the prior calendar year. Do you meet the eligibility definition? 0 no 0 yes If COBRA applies, please select desired billing option: 0 group bill policyholder 0 individual bill continuee If you currently have anyone on COBRA, please submit enrollment form with qualifying event date noted. All Coverages ERISA plan number 501 The Employee Retirement Income Security Act of 1974 (ERISA) requires that each employee benefit plan subject to the Act designate a "Named Fiduciary who shall have authority to control and manage the operation and administration of the plan." If this plan is subject to ERISA and the Named Fiduciary is other than the employer, fill in the information below. Principal Life may not be designated as Named Fiduciary. The "Named Fiduciary" shall be: n/a Designation as Named Fiduciary is accepted. (Required only if the ''Named Fiduciary" is an individual.) By Title It is understood that Principal Life shall not be responsible for any tax or legal aspects of the plan. The employer assumes responsibility for these matters. The employer acknowledges that they have counseled to the extent necessary with selected legal and tax advisors. The obligations of Principal Life shall be governed solely by the provisions of its contracts and policies. Principal Life shall not be required to look into any action taken by the named fiduciary or the employer and shall be fully protected in taking, permitting, or omitting any action on the basis of the employer's actions. Principal Life shall incur no liability or responsibility for carrying out actions as directed by the named fiduciary or the employer. It is further understood that by signing this application, the employer is purchasing insurance and not making an investment. No reserves, undeclared or unpaid experience premium refunds, or interest with respect to claim payments, nor claim proceeds themselves shall be considered plan assets under ERISA. GP 45703-4 Page 3 of4 08/2004 Agreement and Signatures 210 . The employer has been informed of the eligibility requirements. The employer agrees that insurance applied for shall not become effective or remain effective unless the employer: a) is actively engaged in business for profit within the meaning of the Internal Revenue Code, or is established as a legitimate nonprofit corporation within the meaning of the Internal Revenue Code; and b) meets the participation and contribution requirements. . The employer agrees that insurance applied for shall not become effective unless the application and any attached page(s) are received, accepted and approved by Principal Life. . If this application is accepted, all group policies will be combined and treated as one policy for the purpose of determining any experience premium refund. . The preexisting condition restrictions for medical and/or long term disability insurance have been explained to and understood by the employer. . The employer understands receipt and deposit of advanced payment is not a guarantee of coverage. If a policy is issued from this application and is accepted by the proposed policyholder, we will apply the premium deposit to the first premium due for such policy. If no policy is put into force, the premium deposit will be refunded. . Premium payment will be monthly unless otherwise indicated. . Acceptance by the employer of any policy or policies issued with this application shall constitute approval of any corrections, additions, or changes specified in the space "For Principal Life Use Only" or as otherwise indicated on this application. . Your agent or broker cannot change or waive any provision of this application or the policy or policies without the written approval of an officer of Principal Life in the home office. . The employer acknowledges and understands that if this application is approved, the group policy will determine all rights and benefits. . The person signing this form for the employer has legal authority to bind the employer for whom application is being made. . The employer agrees to make timely notification of any employee termination, status change, or other material changes that may affect the eligibility of employees or their dependents. Timely notification is no more than 31 days past the actual date of such change. . The employer understands that failure to pay premium when due will be considered a default in premium payment and coverage will terminate at the end of the grace period. If coverage is terminated for nonpayment of premium, premium through the grace period is due and will be collected. The employer understands that coverage may also be terminated for other reasons as provided in the group policy. NOTE: If Principal Life determines, due to requirements of law or because of our own underwriting criteria, to issue our group insurance through a multiple-employer group insurance trust, the employer hereby subscribes to and agrees to the terms of that trust. Any person who, with intent to defraud or knowing that he or she is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement, may be guilty of insurance fraud. Fraud or misrepresentation may be grounds for nonrenewal or termination under the terms of the group policy. Employer (company name) City of Salina Signed by st be an office Officer's title City Manager Agent's license number I Date signed /2-/t (0& Signature of soliciting agent(s) (If more than one, all must sign.) Date signed I Date signed I For Principal Life Use Only GP 45703-4 Page 4 of 4 08/2004 Mailing Address: I Principal Life I POlicyholder Census Des Moines, IA 50392-0002 Insurance Company Enrollment Agreement Account number The following is a summary of the Policyholder responsibilities for insurance coverage. As the Policyholder for this group insurance, your responsibilities include (but are not limited to) the items listed below. Please refer to the Group Policy/Policies for additional Policyholder responsibilities such as participation and contribution requirements. As the Policyholder for the above group insurance, I agree to: . Obtain and maintain a completed group enrollment form from each eligible employee applying for or waiving a coverage or for a benefit increase. . Provide a Preexisting Condition and Special Enrollment Rights form to each person applying for medical coverage. . Maintain the enrollment forms and other necessary records to enable Principal Life Insurance Company to determine the current classification, benefits, current beneficiary designation, and termination data for each insured person. Any changes in beneficiary designations must be maintained and made available to Principal Life upon request. . Verify that the insureds are covered under the terms of the Group Policy, considering eligibility for coverage, effective date, and termination. . Provide health statement forms to applicants as required and ensure that those forms are submitted to Principal Life on a timely basis. . Make all records and data related to this group insurance available to Principal Life for audit upon request, including home addresses of insured employees. . Provide notice to eligible employees regarding the change in insurance carriers and distribute benefit and contribution information to each eligible employee either via online access or paper copy (including, but not limited to, the Benefits At A Glance (BAAG) and a booklet-certificate). Group Name City of Salina Job title City Manager Polic erSig~ Da /2/1/00 GP 50522 Page 1 of 1 01/2004