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Contract - Met Life - 9/13/2018 Group, Voluntary &Worksite Benefits M%e-tL1 f e 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 C"xMUj)VO11.18,Vtrork,((e, 9 i3�ttf w CUSTOMER AGREEMENT i` jI i` 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 i� 14 Executive Vice President Li Title Signr6 of horized Representative M e 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