Contract - Minnesota Life - 9/13/2018 Group Accidental Death and Dismemberment
Insurance Policyholder's Application MINNESOTALIFE
Minnesota Life Insurance Company-A Securian Company
400 Robert Street North • St.Paul,Minnesota 55101-2098
Application is hereby made to Minnesota Life Insurance Company for a Group Accidental Death and Dismemberment
insurance plan providing benefits as indicated below.
Applicant(policyholder)
City of Round Rock
Nature of business Plan effective date
City Government January 1, 2019
Address(street,city,state,zip code)
231 E. Main St, Ste. 100 Round Rock, TX 78664
Associated companies
Contact name Title Phone number Faxnumber
Tyler Jar[ Benefits Manager 512-341-3143 1512-218-5493
Email address
tjarl@roundrocktexas.gov
Plan Design:Please indicate the Group Accidental Death and Dismemberment plan by checking the appropriate
boxes below. For all boxes marked "Other`; describe in the Comments section below.
Policyholder Employee Paid
Paid Basic _(Supplemental)
Group Employee Accidental Death and Child Eligibility(subject to state limitations):14
Dismemberment ❑ days to 19 years;23 years if full-time student.
Family Coverage ®Other:
Spouse and Child ❑ Live birth to age 26
Spouse only ❑ ❑
Child only ❑ ❑
Other ❑ ❑
Schedule of Insurance: Please complete this section or attach a Schedule of Insurance.
Amount of Terminates at the earlier of
Insurance Minimum Maximum Employee Retirement or Age 70:
❑ Yes
Employee Basic lx annual salary $10,000 $100,000 ® No
❑ Yes
Employee Supplemental $10,000 to$500,000 $10,000 $500,000 ® No
❑ Yes
Spouse %of EE amt-see below $250,000 ❑ No
❑ Yes
Child %of EE amt-see below $75,000 ❑ No
NOTE: There may be limits on the amount of insurance available to the employee, a spouse, or children according to the
governing jurisdiction of the group policy and the employee's state of residence.
COMMENTS
Spouse and Child amounts are a percentage of the elected Employee amount as follows:
Spouse (with children) : 400
Spouse (no children) : 500
Child (with spouse) : 100
Child (no spouse) : 150
02-30430
Employee Eligibility
Classes: 0 All Employees ❑Other:
Minimum hours per week an employee must work for his or her employer: 30 hours per week.
Waiting period before becoming eligible for insurance:
Current Employees: 0 days. First of the month following 0 days.
Future Employees: n/a days. First of the month following hire days.
When do changes in coverage amounts due to salary or classification changes occur?
❑ First of the month following the change.
❑At the policy anniversary.
❑ Other:
Are retirees or any other designated persons not actively at work to be included in this plan?
❑ Yes Z No
If yes, please attach a list of retirees and/or other designated persons for whom we have agreed to provide
coverage, including ages and amounts of insurance as well as the circumstances under which we are providing
coverage. These individuals are excluded from the actively at work and the minimum hours per week requirements
of the group policy.
Administration
Who will administer this plan? ❑ Minnesota Life Policyholder
If the policyholder administers the plan, the policyholder will maintain records(including beneficiary designations,
insurance amounts, and name and address changes) and provide Minnesota Life with monthly information(number
of insureds, total amount of insurance, premium rate, and total premium)and annual participant data.
Minnesota Life Agrees To Provide:
1. Accidental Death and Dismemberment insurance to those who have satisfied the eligibility requirements.
2. Enrollment materials necessary to implement the plan of insurance.
3. All underwriting, claims, and actuarial services as necessary.
The Policyholder Agrees To Provide:
1. Employee information to Minnesota Life to facilitate preparation of enrollment materials and plan set-up if required.
2. Payroll deduction facilities to collect premiums from insured employees, accounting for such premiums, and
remittance of such premiums to Minnesota Life.
3. Reasonable administrative assistance to Minnesota Life with regard to notification of insured terminations,
changes in payroll deduction authorizations, and the distribution of materials to employees.
Either Minnesota Life or the Policyholder can terminate the group policy by giving the other party 31 days advance written
notice. The group policy is effective (date) January 1, 2019 and unless terminated by either party,will remain in effect
for a one year period and shall thereafter renew for additional one year periods.
FOR THE POLICYHOLDER
Policyholder
City of Ro
und Rock gY Q c� TitMale or Date
y
Employes identitic tion number Signature
74-6017485 X
FOR MINNESOTA LIFE
Agent,broker or representative
Agency Minnesota Life agency number Date
Agent,broker or representative license Signature
X
Group Term Life Policyholder Application MINNESOTA LIFE
Minnesota Life Insurance Company-A Securian Company
400 Robert Street North • St.Paul,Minnesota 55101-2098
Application is hereby made to Minnesota Life Insurance Company for a Group Term Life insurance plan providing life
insurance and other supplemental benefits as indicated below.
Applicant(policyholder)
City of Round Rock
Address(street,city,state,zip)
231 E. Main St, Ste. 100 Round Rock, TX 78664
Contact name Title Telephone number
Tyler Jarl Benefits Manager 512-341-3143
E-mail address Faxnumberr
tjarl@roundrocktexas.gov 512-218-5493
Plan Design:Please indicate the Group Term Life plan by checking the appropriate boxes below.
The Accelerated Benefits Rider is always included.
Plan Design Policyholder Paid (Basic) Employee Paid (Supplemental)
Group Employee Term Life ❑✓ E)
Employee Accidental Death and Dismemberment ❑ [1
Employee Waiver of Premium ❑ ❑
Group Spouse Term Life ❑ ❑
Spouse Accidental Death and Dismemberment ❑ ❑
Spouse Waiver of Premium ❑
Dependents Term Life Rider(Spouse and Child) ❑ ❑
Child Term Life Rider ❑
Other: ❑ ❑
Financials: Non- Standard Low Remit Cost Plus Uni-Nicotine Nicotine
Participating Participating Rates Rates
Employee Basic Z ❑ ❑ ❑ Z ❑
Employee Supplemental* 0 ❑ ❑ ❑ Z ❑
Spouse* 0 ❑ ❑ ❑ Z ❑
AD&D* Z ❑ ❑ ❑ N/A N/A
Child* Z ❑ ❑ ❑ N/A N/A
Packaged Dependents* ❑ ❑ ❑ ❑ N/A N/A
*Standard is Non-Participating
Who will administer this plan.? ❑ Minnesota Life Policyholder
If the policyholder administers the plan, the policyholder will maintain records(including beneficiary designations,
insurance amounts, and name and address changes) and provide Minnesota Life with monthly information(number
of insureds,total amount of insurance,premium rate and total premium)and annual participant data.
Minnesota Life Agrees To Provide:
1. Life insurance to those who have satisfied the eligibility and any underwriting requirements.
2. Enrollment materials necessary to implement the plan of insurance.
3. All underwriting, claims and actuarial services as necessary.
The Policyholder Agrees To Provide:
1. Employee information to Minnesota Life to facilitate preparation of enrollment materials and plan set-up if required.
2. Payroll deduction facilities to collect premiums from insured employees, accounting for such premiums and
remittance of such premiums to Minnesota Life.
3. Reasonable administrative assistance to Minnesota Life with regard to notification of insured terminations,
changes in payroll deduction authorizations and the distribution of materials to employees.
Either Minnesota Life or the Policyholder can terminate the group policy by giving the other party 31 days advance
written notice. This group policy is effective (date) January 1, 2019 and unless terminated by either
party, will remain in effect for a one year period and shall thereafter renew for additional one year periods.
FOR THE POLICYHOLDER
Policyholder Employeridentiiication number
City of Round Rock 74-6017485
Signature Title Date_4 �'��• ��
X Mayor
FOR MINNESOTA LIFE
Agent,broker or representative Agent,broker or representative licensfe Minnesota Life agency number
Agency Signature Date
X
03-30565 Minnesota Life 1
Financial security
for the long run. S E C U R I A N
RATE CONFIRMATION
1. Policyholder: City of Round Rock
2. Policy Number(s): 34627, 34629
3. Insurance Product(s): Basic Term Life and AD&D, Employee and Spouse Supplemental Term Life,
Child Life, and Voluntary AD&D
4. The insurance rates included in this rate confirmation are net of commissions.
5. Underwriting company: Minnesota Life Insurance Company
6. Rate Coverage Period: January 1, 2019—December 31, 2023
Premium Rates:
Basic Life: $0.086/$1,000/month
Basic AD&D: $0.020/$1,000/month
Employee and Spouse Supplemental Term Life:
Aqe Rate/$1,000/Month
Under 25 $ 0.060
25-29 $ 0.070
30-34 $ 0.090
35-39 $ 0.100
40-44 $ 0.120
45-49 $ 0.220
50-54 $ 0.420
55-59 $ 0.660
60-64 $ 0.720
65-69 $ 1.330
70-74 $ 2.070
75* $ 2.380
*Please note, rates increase past 75 and will be provided upon request
Employee Voluntary AD&D: $0.025/$1,000/month
Family Voluntary AD&D: $0.035/$1,000/month
Child Life: $0.120/$1,000/month
Securian Financial Group
By G ` c7h Date August 23, 2018
Susan Munson-Regala
Title 2nd Vice President and Actuary
ACKNOWLEDGEMENT BY AUTHORIZED REPRESENTATIVE OF POLICYHOLDER
This document confirms that the rates stated above are the agreed upon rates for the specified policy
numbers. These rates will be charged for coverage amounts effective during the Rate Coverage Period
listed above. Securian reserves the right to adjust the rates at any time in the event of plan design
changes, modifications to the definition of eligible employees, or significant demographic changes in the
group. We define significant changes to mean a change in the volume within a coverage or across
coverages of more than 15%. Actives and retirees are considered independent coverages. The
baseline for calculating the total change in volume will be the volume provided in the 2018 RFP census.
By Ada Date 4' L '(Q2
1'
Title 0/ 4ic1 11/16t2Iblfri
Rate Confirmation Page 2 of 2
CERTIFICATE OF INTERESTED PARTIES FORM 1295
1 of 1
Complete Nos.1-4 and 6 if there are interested parties. OFFICE USE ONLY
Complete Nos,1,2,3,5,and 6 if there are no interested parties, CERTIFICATION OF FILING
1 Name of business entity filing form,and the city,state and country of the business entity's place Certificate Number:
of business. 2018-398543
Minnesota Life Insurance Company
Saint Paul,MN United States Date Filed:
2 Name of governmental entity or state agency that is a party to the contract for which the form is 08/30/2018
being filed.
City of Round Rock Date Acknowledged:
3 Provide the identification number used by the governmental entity or state agency to track or identify the contract,and provide a
description of the services,goods,or other property to be provided under the contract.
RFP No. 18-020
Group Term Life and AD&D
4
Nature of interest
Name of Interested Party City,State,Country(place of business) (check applicable)
Controlling I Intermediary
Securian Finacial Group, Inc. St. Paul, MN United States X
Hilger,Chris St. Paul, MN United States X
Zaccaro,Warren St. Paul, MN United States X
Shay, Bruce St. Paul, MN United States X
Connolly,George St. Paul, MN United States X
5 Check only if there is NO Interested Party. ❑
6 UNSWORN DECLARATION
My name is Susan Munson-Regala and my date of birth is 11/10/1966
My address is 400 Robert St N St. Paul MN , 55101 USA .
(street) (city) (state) (zip code) (country)
I declare under penalty of perjury that the foregoing is true and correct.
Executed in Ramsey County, State of Minnesota on the day of 12018
(month) (year)
Signature of authorized agent of contracting b iness entity
(Declarant)
Forms provided by Texas Ethics Commission www.ethics.state.tx.us Version V1.0.6711
CERTIFICATE OF INTERESTED PARTIES FORM 1295
10f1
Complete Nos.1-4 and 6 if there are interested parties. OFFICE USE ONLY
Complete Nos.1,2,3,5,and 6 if there are no interested parties. CERTIFICATION OF FILING
1 Name of business entity filing form,and the city,state and country of the business entity's place Certificate Number:
of business. 2018-398543
Minnesota Life Insurance Company
Saint Paul, MN United States Date Filed:
2 Name of governmental entity or state agency that is a party to the contract for which the form is 08/30/2018
being filed.
City of Round Rock Date Acknowledged:
09/05/2018
3 Provide the identification number used by the governmental entity or state agency to track or identify the contract,and provide a
description of the services,goods,or other property to be provided under the contract.
RFP No. 18-020
Group Term Life and AD&D
4
Nature of interest
Name of Interested Party City,State,Country(place of business) (check applicable)
Controlling Intermediary
Securian Finacial Group, Inc. St. Paul, MN United States X
Hilger, Chris St. Paul, MN United States X
Zaccaro,Warren St. Paul, MN United States X
Shay, Bruce St. Paul, MN United States X
Connolly,George St. Paul, MN United States X
5 Check only if there is NO Interested Party. ❑
6 UNSWORN DECLARATION
My name is and my date of birth is
My address is
(street) (city) (state) (zip code) (country)
declare under penalty of perjury that the foregoing is true and correct.
Executed in County, State of on the day of 20
(month) (year)
Signature of authorized agent of contracting business entity
(Declarant)
Forms provided by Texas Ethics Commission www.ethics.state.tx.us Version V1.0.6711