CM-11-04-081ROUND ROCK, TEXAS
PURPOSE. PASSION. PROSPERITY.
Item Caption:
City Manager Approval Summary Sheet
Consider authorizing the City Manager to execute a "Request for Group Insurance
Amendment" with Standard Insurance Company.
Approval Date:
Department: Human Resources
Project Manager:
Teresa S. Bledsoe, Director,
Human Resources
Item Summary:
Consider authorizing an amendment to the Standard Insurance Company provided EAP service by
increasing the Face to Face Assessment and Counseling Sessions from three visits to six visits.
Strategic Plan Relevance:
Cost: $2,400 ( .25 per employee per month @ 800 employees)
Source of Funds: General/Utilities
REV. 6/10/10
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Request for Group Insurance Amendment
Standard Insurance Company
900 SW Fifth Avenue
Portland, OR 97204-1282
Employee Benefits Consultant: Ben Anderson
Employee Benefits Service Representative: Lonna Owens
Employee Benefits Sales and Service Office: San Antonio
Employer Name: City of Round Rock
Group Number: 148447
As an authorized representative of the Employer, I request that Standard Insurance Company (`The
Standard") amend the above Employer's coverage under the Group Policy to make the following
change(s):
Please change to the 6 Face to Face EAP model. The rate is $.25/member per month.
I request that the amendment become effective on 5/1/2011. I understand that the amendment will
not become effective unless approved and issued by The Standard.
I request that the amendment be approved by The Standard subject to The Standard's usual
underwriting requirements, including, if applicable, Evidence of Insurability or a Pre-existing Condition
provision.
I understand that the amendment, if approved by The Standard, will be issued in the policy language
customarily used by The Standard.
I understand that any increase in Insurance for a Member who is not Actively At Work all day on the
Member's last regular work day before the scheduled effective date of the amendment will be deferred
until the first day after the Member completes one full day of Active Work.
I request that the amendment, if approved and issued by The Standard, become effective by its terms
without any further acceptance by the Employer, and that a copy of this Request for Group Insurance
Amendment form be attached to and made a part of the amendment.
Sign Name:
Authorized Representative
Print Name: SrEV E (oRWcob
Title:
Date:
Ll PT) MAN CsCia-
•412127/ l
Standard Online Amendment Request 4/27/2011 12:47 PM