Contract - Met Life - 9/13/2018 Group, Voluntary &Worksite Benefits M%e-tL1
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Metropolitan Life Insurance Company
200 Park Avenue
New York, NY 10166
Statement of Responsibility
MetLife will be responsible to the group policyholder for the performance of its administrative obligations under the group
policy, this agreement and any other written agreement between MetLife and the group policyholder. If MetLife uses a
third party in connection with any of MetLife's administrative obligations, MetLife will remain responsible to the group
policyholder for the performance by the third party of those administrative obligations. The third party will work under the
control and direction of Metlife and Metlife will be solely responsible for the acts, errors and omissions of the third party.
The group policyholder will be responsible to MetLife for the performance of its administrative obligations under the group
policy, this agreement and any other written agreement between MetLife and the group policyholder. If the group
policyholder uses a third party in connection with any of the group policyholder's administrative obligations, the group
policyholder will remain responsible to MetLife for the performance by the third party of those administrative obligations.
The third party will work under the control and the direction of the group policyholder and the group policyholder will be
solely responsible for the acts, errors and omissions of the third party.
To be completed by Policyholder:
Craig Morgan I" t 0 F_
(Name of Authorized Representative) (Title of Authorized Representative)
City of Round Rock Texas
(Signature f Policy
VI Authorized Representative) (Group Policyholder Name)
Sign�eed fat: ht '�p /��� 0 IQ�
(City) (State) Date (MM/DD/YYYY)
To be completed by Metropolitan Life Insurance Company:
,James W. Reid
Executive Vice President Date (MM/DD/YYYY)
Group.Voluntary &Worksite Benefits
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CUSTOMER AGREEMENT
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City of Round Rock Texas
221 East Main Street
ROUND ROCK, TX 78664
09/04/2018
3
Dear Laurie Hadley
Thank you for choosing a benefits program from Metropolitan Life Insurance Company ("MetLife") and the
MetLife family of Companies. We are excited to be providing benefits for City of Round Rock Texas
employees. To get started, please sign a copy of this letter below.
3'.
The benefits you have chosen for your Critical Illness Insurance, Accident Insurance are listed in the
schedules already provided to you. If your MetLife benefit offerings change, we will reflect those changes in a
new schedule.
METLIFE'S RESPONSIBILITIES:
1. MetLife will offer the benefits listed on the attached schedules ("MetLife Benefits")to all eligible
individuals. Individuals who obtain benefits are referred to as "Participants".
2. For each of the MetLife Benefits listed on the attached schedule, MetLife will provide as applicable
either: a group insurance policy and insurance certificates; individually underwritten insurance policies;
a detailed benefits schedule; or one or more administrative agreements. These documents will detail
the benefits provided, costs, effective date, and other important terms. Nothing in this letter changes
any of the terms of the group or individual insurance policies, certificates or other applicable
administrative agreements.
1 MetLife will comply with all laws applicable to MetLife's activities in connection with the MetLife
Benefits.
4. MetLife will provide information and materials that eligible individuals need to understand the MetLife
f Benefits.
5. MetLife will process eligibility information and payroll deductions in accordance with MetLife's policies
and procedures for each MetLife Benefit. MetLife will be responsible for all pricing and individual
underwriting decisions.
6. MetLife will provide account management services to City of Round Rock Texas and customer service
to eligible individuals.
7. MetLife will treat all non-public personal information about eligible individuals in a confidential manner
P and in accordance with all applicable laws.
8. Participants no longer employed by City of Round Rock Texas (and where applicable, their
dependents) may continue certain benefits with MetLife in accordance with MetLife's policies and
procedures.
(con tin ued)
. _. .._ .
City of Round Rock Texas'S RESPONSIBILITIES:
1. City of Round Rock Texas will communicate the MetLife Benefits to all eligible individuals and
distribute enrollment materials. City of Round Rock Texas will provide MetLife with full access to the
eligible population. City of Round Rock Texas will perform its administrative obligations to the fullest
extent to drive maximum participation in MetLife Benefits by all eligible individuals. [For Auto &
Home coverage, City of Round Rock Texas will provide employee contact information to support
home mailings managed by MetLife up to four times throughout a calendar year. The campaigns will
be chosen by MetLife, and can be customized by adding the employer logo.]
2. City of Round Rock Texas will process enrollments and will report to MetLife the identity of all
Participants. For certain MetLife Benefits, MetLife requires that City of Round Rock Texas will
provide a list of all Eligible Employees and provide regular updates thereto. City of Round Rock
Texas will provide this if required to do so. MetLife and City of Round Rock Texas will agree upon
the timing and format of this enrollment information.
f 3. City of Round Rock Texas will not use the name or Brand of MetLife or create or distribute materials
regarding the MetLife Benefits without MetLife's approval.
4. City of Round Rock Texas will comply with all laws applicable to City of Round Rock Texas's
activities in connection with the MetLife Benefits.
5, Where Participants contribute to the cost of the MetLife Benefits, City of Round Rock Texas will
provide payroll deductions for amounts due in connection with the MetLife Benefits and will remit
payments to MetLife.
6. City of Round Rock Texas will be responsible for any filings required by the Department of Labor or
other Federal or State agencies. Upon request, MetLife will provide applicable information
necessary to make such filings.
7. If City of Round Rock Texas is represented by an insurance agent or broker for purposes of a
MetLife Benefit, City of Round Rock Texas agrees to inform MetLife of any change in its insurance
agent or broker.
!!-E
We look forward to serving your benefit needs! If the terms of this letter are acceptable to City of Round Rock
Texas, please sign below.
Very Truly Yours, Accepted and Agreed to:
METROPOLITAN LIFE INSURANCE COMPANY City of Round Rock Texas
Craig Morgan
72 Name of Authorized Representative
By Title Authorized R-presentative
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Executive Vice President
Li Title Signr6 of horized Representative
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Metropolitan Life Insurance Company
200 Park Avenue, New York, New York
APPLICATION FOR GROUP INSURANCE
The applicant named below is applying for Group Insurance to provide coverage for the class(es) of persons specified
below.
APPLICANT DATA
1. Full legal name of Applicant: City of Round Rock Texas (the"Policyholder")
2. Address: 221 East Main Street City ROUND ROCK State TX Zip 78664
EFFECTIVE DATE
The effective date of the applied for group insurance will be 01/01/2019 subject to MetLife's acceptance of
this application and the applicant's payment of the Premium due on or before such date.
SITUS
Group Policy forms will be issued for delivery in and governed by the laws of TEXAS
COVERAGE DATA
Employees/Members Dependents
Critical Illness Insurance Critical Illness Insurance
Accident Insurance Accident Insurance
PREMIUM DATA
Premiums will be paid: ® Monthly ❑ Quarterly ❑ Annually ❑ Other:
Attached is an advance payment of: $0
AGREEMENT
The Applicant signing below agrees to accept the terms and provisions of all Group Policy forms issued pursuant to
this application; including all Exhibits, amendments and endorsements, if any.
Fraud Warning. Any person who knowingly and with intent to defraud any insurance company or other person files an
application for insurance or statement of claim containing any materially false information, or conceals for the purpose
of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime
and subjects such person to criminal and civil penalties.
Signature of Applicant's Authorized Representative
Signed at: City VZU NP 12ae-14— State �Q (� Date: q • �Zj•
Name of Authorized Representative Craig Morgan
Title of Authorized Represent tive M a�y 6
Applicant's Signature
Signature of Licensed Met ife Ag t or Resident Agent as required by law
Agent's State License No. 985308 Date: 08/23/2018
Name of Agent: Andrew Clifton
Agent's Signature AviArm CWo-vv
GAPP13-02
TX