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ORDINANCE NO. 12,606
AN ORDINANCE AUTHORIZING THE CITY MANAGER TO
EXECUTE AN AGREEMENT PROVIDING DISABILITY
INSURANCE FOR EMPLOYEES OF THE CITY; REPEALING
SECTION 2 -24 OF THE CODE OF ORDINANCES; AND
FOR OTHER PURPOSES
BE IT ORDAINED BY THE BOARD OF DIRECTORS OF THE CITY OF
LIFrLE ROCK, ARKANSAS.
SECTION 2. The City Manager is hereby authorized, acting
for and on behalf of the City to execute a contractual agreement
providing disability insuance for employees of the City of Little
Rock with the company set forth as follows providing benefits
recommended by Peat, Marwick and Mitchell and /or Galbraith &
Green, consultatns to the City.
a) Employee insurance contract against loss due to
disability resultlig from accidental bodily
injury or from sickness awarded to The Mutual
Benefit Life Insurance Company. A specimen
contract for this coverage is attached hereto
and made a part hereof the same as though set
out herein word for word.
Total premium for the herein provided coverage shall be paid
by the City of Little Rock.
SECTION 2. Section 2 -24 of the Code of Ordinances Oer-
taining to disability retirement is hereby repealed,effective February
1, 1972.
SECTION 3. This Ordinance shall be in full force and
effect from and after its passage.
PASSED: January 18, 1972
ATTEST: APPROVED:
City C1 rk Mayor
<tG' 7`?
The Mutual Benefit Life Insurance Company
herein called the Company
In consideration of the payment of premiums by the Policyholder agrees to
pay the benefits herein provided with respect to those members of the group
described in this policy who fulfill all the requirements to be entitled to
benefits in accordance with the provisions on this and other pages of this
policy.
Policy Number 0 0000 -5
Policyholder THE A. B. C. COMPANY
Effective Date This policy takes effect on JuCCly(3�, 1.967
Issue Date July 7, 1967
Policy This policy provides ins �a extent set forth therein, against loss
Description due to disability roe mg, cidentai bodily injury or from sickness.
Basic Policy The amount of premi alculated according to the method described
Premiums in Section A8. �.
Premium Due Dates The first pre on the effective date and subsequent premiums are
due each rea ter on the first day of the month.
Policy Anniversary The policy anhiWreary in each year is the anniversary of the effective date.
Delivery This policy is delivered in New Jersey and is governed
by its laws.
24 Hour Coverage Secretary
Long Term Attest#
Disability Insurance
Ae lat.r�r
Contributory S --
Ammai Dividends
HOME OFFICE
OLTD -621 1R 101
GROUP POLICY SCHEDULE
general group
The employees of the Policyholder.
eligible classes
The eligible classes of the general group shall comprise each active,
of the
full -time employee who is less than the Limiting Age (hereinafter de-
general group
fined), except any such person employed on a temporary basis.
For the purposes of this policy, any person who works less than 30
hours per week shall not be considered full -time.
The Limiting Age referred to above (and in the further provisions of
'
this policy) is 64 years and 9 months.
present service
None
requirement
future service
Three months
requirement
entry date
An eligible person will become insured on the day as of which he has
fulfilled all the requirements of Sections B2 and B3, subject to the
provisions of Section B4 of the policy.
qualifying
Six consecutive months of disability.
period
maximum
Benefits will not accrue after the disabled personts sixty -firth birth -
duration of
day provided, however, that for persons insured who enter a benefit
benefits
period between the ages of 64 years and 64 years and 6 months inclusive,
a minimum benefit period is hereby, established, which minimum benefit
period shall be one year from the expiration of the qualifying period.
schedule
The Schedule Amount is an amount equal to 60% of monthly earnings (as
amount
defined in accordance with Section 8 of Benefit Agreement No. I) sub-
,ect to a Maximum Schedule Amount of $1,200.
minimum
Number: 10 Percentage: 75%
participation
requirements
CEPS -100
FAI'.T A GENERAL
Entire Contract Al This polic� and the errifentio-n, ,,Itich 7,,PS a•tacl-,9d
when tI,is policy !as issund, tvTo0or with the written if
any, of Mse persons who are instwed under thi,7
cntii'e contract.
ty A2 it, agent hos tc• ch-�ni -,r ti-is oi, U, any of z
provi.;icinj No cMng, in this poncy or-ll val.`d unleyz
the Presiderit, P Vice "residen-, or
of the WIma EnA zwk :jpvoial bn crK. ,-.0 or L,y
SiMWLA by Inp Pc,l0*hWTPr orl Me Cwpio"
Statements A3 All :;t-j.tements 1:.aCle by thr Policyholder or. by t1he per: oils ins d
hereunder; iii the abs'nce of f--EvL - all by d---_nf,d
not wa=cnties, st:-tement by the P&Ac•-!.D!&-i or 1:,, ari insur--!C'.
son n,-de for the
Of 'c-,4n_ insjr .,.co sha2l -Go--d
irsu3�;=c oi- reduce !"nwfj'L.z i-,erL-,�nder in a
instruilIent signed 'j-,7 or the inv=d pcmon, a uTy of
whivi ii::, ber'n fur.n,S,h2!°. to su,'b or t:) pc-,rSon or
legal
All The rlolicylh -,der is c'..:nc'r of poi. Cy a & Miy sn"OF:
pany to chin ,-,e ,., e.,iend the I-olfc: -jj 01 �j!,,
I - -- 1, L
sured 1,crel,--dcr, but any i1 CaaTl or vall bn y1t%ont roc-
judice to any :.�2aim a-r, sing L)rioy' to the effecti-,.re t a,:� of )r
amndwnt.
D-,it, A5 We Policylvol lop n W fiory gh to whe Cupoly tlrl:y
imsmKd unKr Ws policy Kqzncr Wit!, injor:,-Iation the
ir3 -,-- in ora-,,r -,0 1, r, I ii---,e tt I e . -r fec-, -v-- late for i11 di v ",I I; a� n-:
thy of bcnefit and '!,e premlu:�i -,U 1,- Cliarc:ed. .The
also funAsh pomqptly P.1 J. cc)n,_e.,nirE,
cyawaLs and teivAwtQns of nwn. Out TvllaWWer va"nz Z: wrM
thL Co: pany at any r2asonable zo inqncu all ocrtinrnt rz,,--ords
an purpose r,-!.Lating to the pr: vision of this _ ;:13ey.
Nisstatevtent Of A6 if it has been detenhm�rl that any essential - data perta-*.nin,-,, to any
Essenti :- D.-to persor_ insuaed under ti,io, policy tins beer, om 61, :I,i,,,;,tated, ti-« am6l;.nt
of ben-efit will be tl-,�-t amount whichwould Inve boon in. f3-.c-2 if
been x.o ofcJ-ssion or misstntcmmt. will pay to
or the Company will refund to t!ic Polic,yhold,-,r, whichever tlh,' ,,1,ny lj(,
the amoinit necessary to adjust thz: p,--eniiums paid to t.ie coricu-, nmo -unt, T!-�
Corpany will riot inc..u, any liability or responsibility in ccrinectir-i.,
nlisstatzym nt or CM03ion of my such essential �ata bacr . :,zF.king tiie ad.,ust-
raeent required bey this sect-en.
GLTD-621 A101 GPS-I
U-3308-G (2-66)
section E10VTS 0 [T I
Sex ant,' Nu,:i))er AIO VeCuired by th'-- context Of this p01_ 4yr
the sinSulav, th° s-'InF•-11�r th_ plui--1 and the mascaiire
No E feet O-n All, This policy is not in iiru cf and does not affect a.n. r is for
Iork.menls CorL °nsation -coveraEE, by co,-.,)En 2t-Jon insurance.
No AssiEn:'Iallt 1,12 To the extent permait-ted by law, the benefits oil payments under: "his
policy shall not be azsiEnable or otherwise transferable, nor suljec`
-' C r t
any I Y
y claim of any creditor of a person insured under this po
process by any creditor of the insured person.
Benefits A1.3 The benefits bnder this policy are those provided by A-97-ec-
rivFnt(s) attached to and forming a part of this policy, which
ment(s) is (are) as
Benefit Agreement No. 1, L,'.)nE Term Disability ir'.31irance.
6 2 1 A! 0
Part B REQUIREMENTS FOR INSURANCE COMAGE MMM THE POLICY
Definition Of B1 An eligible person is a member of an eligible class of the general
Eligible Person group who has fulfilled all the individual eligibility requirements of
Section B2.
General Group (a) The general group shall consist of the persons described in the
Group Policy Schedule. If.the term "Associated Companies" appears
in such description, it means only those firms, companies, corpor-
ations or individuals which are subsidiary to or affiliated with
the Policyholder and which are listed therein.
Eligible Classes (b) The eligible classes of the general group shall consist of the persons
Of The described in the Group Policy Schedule.
General Group
Individual B2 The individual eligibility requirements for a person who is a member
Eligibility of the eligible classes of the general group are as follows:
Requirements
Service The applicable period of continuous service with the Policyholder, or
Requirements an Associated Company (if any are listed in the definition of the gen-
eral group), or both, determined from the Group Policy Schedule. The
Present Service Requirement set forth in the Group Policy Schedule ap-
plies only to persons who are members of the eligible classes of the gen-
eral group on the effective date of this policy. The Future Service
Requirement set forth in the Group Policy Schedule applies to all other
persons who become members of the eligible classes of the general group.
Application B3 He must apply on a form satisfactory to the Company for insurance un-
Requirement der this policy and must agree to contribute toward the payment of premiums,
Unless said application is received by the Policyholder within 31 days
after the other requirements of Sections B1 and B2 are fulfilled
application requirement will be fulfilled only if evidence of in, , is
th
th
bility satisfactory to the Company is furnished at his own expense.
B101
(A) GPS 1 -C -19
(10/67)
TERMINATION OF INSURANCE UNDER THE POLICY
Individual C1 All insurance under this policy with respect to any one person,
Termination subject to the further provisions hereof, shall terminate immediately
Of Insurance when (a) his status changes so that he ceases to be a member of the general
group or of an eligible class thereof as defined in Section B1, (for any
reason, including attainment of the Limiting Age) or (b) he fails to make
when due, any required contributions toward the payment of premiums for
his insurance under this policy.
Cessation of active full -time work with the Policyholder or an Associated
Company, if any are listed in the definition of the general group, solely
because of disability covered by this policy will not cause termination of
insurance under this policy.
Cessation of active, full -time work with the Policyholder or an Associated
Company, if any are listed in the definition of the general group, for any
reason other than disability covered by this policy, shall automatically
constitute termination of membership in the general group and the eligible
classes thereof, provided, however that when such cessation of active, full -
time work is due to disability not covered by this policy, leave of absence,
temporary lay -off or change to part -time employment status, the Policyholder,
at its option and acting on a basis precluding individual selection, may
consider membership in the eligible classes to continue, and thereby continue
the insurance hereunder, following the cessation of active, full -time work
but not beyond the expiration of the calendar month next following the calendar
month during which active, full -time work ceased nor beyond the date insurance
would otherwise terminate in accordance with the further provisions of this
Part C.
Amendment C2 If this policy is amended so as to change the general group or the eli-
Of This Policy gible classes of the general group referred to in Section B1, all insurance
under this policy shall terminate with respect to all the persons affected
by such amendment on the effective date of the amendment unless otherwise
specified in the amendment.
Termination C3 This policy and all insurance hereunder will terminate if any one or
Of This Policy any combination of the following events occurs:
a) the Policyholder notifies the Company in writing that this policy is
to be terminated;
b) any premium remains unpaid at the end of the grace period;
c) the number of persons insured under this policy on any premium due date
or, if premium due dates occur less frequently than monthly, on the first
day of any policy month is less than the Minimum Participation Number
determined from the Group Policy Schedule or is less than the Minimum
Participation Percentage determined from the Group Policy Schedule of
the persons eligible for the insurance, and the Company notifies the
Policyholder that the policy is to be terminated;
GLTD -621 C 101 GPS 1 -C
(A) H- 3305 -G (2 -66)
paxt D CLADASS
iqotica and ?,rocs D1 Writter, notice of claim must be given tc the Compary within 30 days
-Of 03aim the date of the occurence or co7xiencement of any disability ccvered by thi.:;
poltii. Notice. given by or on belmll of the disabled person to the Cc2mps-y
at Its home office, Cr to ar4 aut11oriZcd agent cf the Cora.z.-Pany, with irforr:!�-
tion sufficient to ldent.fy the clakAnb to a person innured nnUr W7 10-
icy shall be deemed notice to tye Co .parry'.
Wvitten procf of disability, trj�-;e::Iler 1rith. certificati.cz. as to any bEneftt,
Cr payments sov.:ces rt'her then thlz policy) refe:,rc_-1 to in
of Benefit 1.Z_,eePi-_nt Nr), i in with ti-_-o or.
?�yn,erit Ttntit, must be ft%r.r:1s:-ied A the Cana,, �_` 7,f ice
90 daa after the end of the Mot nmW :--, lesser' per`_o,.t fo,,
ocyparloo,F be ',.'-able. Subsequ�;nt v_-Att,;n, prc,--fz, Of the
disability anc,' certifications a3 Wo otner en,:; snv_. rayli .,,--nts ?Gust be-
furni,shxo:t to th,: Ctm*po, at so..,. T&SVOW cc tiva, commparl r.,.ay reas-,nebly
require.
Failur,a uo furiAsh sunk nutice Qr jonA W"In the tKM mq.M SM11 W",
tn�,alidate nor reduce ar, Waim if it bc- got t:) bey.;
sonibly pos A tin to fvr:'.Iz:h s,,,,ch not c, c, hln
ouch notice m- proN is MrAsTed as so.
The Cc-,-,Pari�v snall i:,F,, t-
sa"FA�Lwy e�dv=F tl-,at tre -1,1,;ahled po-oin Or ZOnet=l Qtlrg Cr. HS
i.al f
nas fow all bewfits, an -11
other thrri tAls zwAlcy) xvf& F,_ V ':.r S-e: lcr, S �21' ft
No. T In t.!e Cffoet kimiJ, Nnd ":onthi,y
which MY, dinabint parsmi is 2"HWA w.A Chat HY re,&Ped p�wf, for
L'uch ct"Ie'. L.�� pnay ,?nts `iave buc furni�,he ,
Co=, F a, YQ ov Caywa, tjon rowlyL A a no .2C Of' f'_r_ !S'l tC,
t, "Inc f,-'2" d1elive' to
.f JQWZ if such Mms 02 n7�t -r-UCC-iN,d by
aa-v giv-11-3 of S.u.ch. n,-Aice : the clal.n.a-lt I be
demod to ha" exTiMu VA the
of elsability upon s-ulbr.-iitting, the time fixed In -this policy for
fill -nE proofs of disability, written proof covering ti-_e ooe-uiericB, c1—i-
raAer and extent c;f' the dJsability fci' which clain is nede.
?ayr:_E!rit !) l,ec i ;or-acf of sabiliy 2n�,�ued benefits W1.11 1e id
s _ j t _ 1 ,
to the clisabled perswt vanthlir auAng tV. con',!:Iuance of t1rie d_',;ab,*__!-1 fir
by this polla•n mid a%- unp,-.,Id tne
njinatior of s,ch disatility will be upoll
written pi-cof.
D Ai iv
(A)
3FIT URSM-7-il T -ONG r.'LIMA
Policy Mimber
P:) I -I cir, o 1 d e r
Effect-live Date
This Benefit Agreement t--t"—Z ace
Contract
1. This Berefit Ar'r*atMC*'t ILS attached• to ,wd �E-a•e a P.;-rt Of tile -10cb '�:
ntmbe -ed Group Policy. Bir t'-!F Bane it Agr-?e;:n-nt the Gr6-j-p ' .-!:.c y prc,.A."-a.
long tevra iD;;ura-cd
violons hersinaj".-er set t,:)l'n used in thjb -
i, - h is used in any other pvo.�silcn of tl,,� Group 'Folloy any not
er
defined he euri,"er- shall have t',.- same mea'-ilaE in T'rl,'ls nc"Iefit t
a3 J, t ha in F a f L, oche r ; VO "i s 0'
pers;
2. ITIP term "covered uaeij Jr. tt)is Benefit
-'
mein a who is 'nsur---1 t}!.0 !)ol icy ,
ln:!-'--ing cla-Use
If a perFor., v:hc is a ecwies total'ly d!-s',`la,
hereinafter RS L--.-�ult of acclde-,Lal bod-Ily
and retmalns i,) d�s_,bled duracic'n of
-h d p
q u a I ' f y _r c dl r. e r e �L f t -., '� - s - - - .—
Is a �-cv,-- er7. 1*1., ) he re7,,.ins a
for the duration of the o - '. n'-' "-i:) as of day
a-te:y follow ins the erld of tree quall-fY*.nF�, rot,
t'ele COI-T-r-y will 17-r-
ac.-co'-("?nce wlth c
tc ti-Le el-c,-,ptlons sl----l. forth ir. 0.
covered r son sha 'I i bt, ci? re d t. o; a 1.1 1 S abl E-d
Of
is L0 l.:
(a) ,:urInLe- the tu,.*--'ItY—col.a.. *r.-. -.':--,5 of n ,)a! - 'Od Of tOtAl-
11a ander 'C"Icl re(-Ittlar --ire and attend,nce
(o"har than himself) and c•7.pietcly unable to enjage in his
occupation or emlloyme t, and
Ur
lip
BENEFIT AGPJ301 M NO. I LANG TERM DISABILITY INSURANCE (Continued)
Amount Of 8. The amount of benefit payable for a month (or lesser period) of
Benefit total disability shall be the excess, if any, of (a) the Schedule
Amount, over (b), the Offset Amount, which Amounts are determined
as hereinafter set forth. In no event, however, shall such amount
of benefit exceed the Monthly Payment Limit determined in accordance
with the provisions of sub - paragraph (c) below.
The provisions Offset Amount and Monthly Payment Limit to the con-
trary notwithstanding, a Minimum Benefit is hereby established,
which Minimum Benefit shall be the lesser of:
(i) $50 for each full month of total disability after the
expiration of the applicable qualifying period, or,
if such period of total disability is less than one
full month, 1/30 of $50 for each day of total dis-
ability after the expiration of the applicable
qualifying period, and
(11) 10% of the person insured's monthly compensation (as
defined in item (a) below) for each full month of
total disability after the expiration of the applicable
qualifying period, or if such period of total dis-
ability is less than one full month, 1/30 of 10% of
the person insured's monthly compensation (as defined
in (a) below) for each day of total disability after
the expiration of the applicable qualifying period.
Schedule (a) The Schedule Amount is determined from the Group Policy Schedule.
Amount
For each day of a period less than a full month, the Schedule
Amount shall be 1/30 of the amount determined as provided above.
The term "monthly earnings" as used above for the purpose of
determining the Schedule Amount for any one period of total
disability shall mean the disabled person's monthly earnings
from the Policyholder on the Schedule Amount Determination
Date coinciding with or last preceding the commencement of
the period of total disability. The Schedule Amount Deter-
mination Date shall be each policy anniversary that occurs
after the commencement of covered person status, and prior
to the first such policy anniversary, the date of commence-
ment of covered person status. In determining monthly
earnings as provided above, commissions, overtime pay,
bonuses, and any other special compensation shall be ex-
cluded. If the Policyholder or an Associated Company is
a Proprietorship, Partnership, Professional Corporation or
Professional Association, monthly earnings for the principals
involved shall consist only of the disabled personts "draw"
or salary and shall not include profits, dividends or return
of capital.
GLTD -623 300 (FSS) GPS 2
(A) x 3+57 G ( 5/71)
BM IT AGIUMMM NO. I LONG TERM DISABILITY INSURANCE (Continued)
The "other benefits and payments" referred to above are as follows:
M any salary, wages, commissions or other similar remuneration that the disabled
person receives or is entitled to receive, from the Policyholder, or from any
gainful occupation or employment in which the disabled person actually engages;
and
(ii) any retirement benefits, or periodic benefits 'in the nature of retirement bene-
fits, that are provided, whether or not pursuant to an insurance or annuity
contract, under or by an employee benefit plan or arrangement for which the
Policyholder shall have paid, directly or indirectly, all or a portion of the
cost or made payroll deductions; and
(iii) any periodic payments or benefits which replace or are paid in addition to a
life insurance death benefit and are provided, in connection with any acciden-
tal bodily injury or sickness, under or by any group, franchise or wholesale
insurance contract with the Company or another insurance carrier; and
(iv) any periodic benefits for loss of time in connection with accidental bodily in-
jury or sickness that are provided (x) under or by any group, franchise or
wholesale insurance contract with the Company or another insurance carrier,
other than a group, franchise or wholesale insurance contract for which the
Policyholder shall have paid (directly or indirectly) all or a portion of the
cost or made payroll deductions, or (xx) under or by any non - statutory employee
health or welfare benefit plan or arrangement (other than a group insurance
contract), for which plan or arrangement the Policyholder shall have paid,
directly or indirectly, all or a portion of the cost or made payroll deductions.
Any benefits or payments that are referred to above in connection with the Offset Amount
or Monthly Payment Limit shall, for the purposes of this Benefit Agreement, be considered
to be provided with respect to the disabled person notwithstanding that he has not ef-
fected timely or proper pursuit of claim therefor or claim therefor is pending, where it
is reasonable to believe that the disabled person would be eligible for such benefits or
payments but for the failure to effect timely pursuit of claim or is eligible for the
benefits or payments for which claim is pending , as the case may be.
If, after the Company has made one or more payments under this Benefit Agreement with
respect to a disabled person, it is determined that the amount of benefits from sources
other than this Benefit Agreement, that should have been considered in determining the
Offset Amount or the Monthly Payment Limit in connection with any such prior payment is
greater or less than what was so considered, such prior payments under this Benefit
Agreement shall be retroactively adjusted accordingly.
Exceptions 9. This Benefit Agreement does not provide benefits for
A. that portion of any period of disability when the disabled person is confined in
any penal or correctional institution as a result of conviction for a criminal or
other public offense, or
500 x 3363G (5/71)
(A) GPS 2 (rev. 5/15/71)
FSS
BENEVII AGIIF-E.S!V�- No. : LOZir, 11EEM, DISABI-.�:2'171 (Continued)
B. any total disability cased Q
(1) wa3.-, wheth- r declar°d '-)r and cia-:. a
,-i, or ry act of war; or
(2) seltnnflRcted injur; of any kind. 15tia sane
jusane: cr
(3) Dar AuVating W, or in consevyQce ci 1-6 90---
comaisOan of an oa.,a:.ilt or feljny; or
(4 'Ir
AGAWn or
thiw; 'i s a b i 1 i t Y c G 7---'w
!�ot ar).)Iy to total ,
aft,a--- Of three o- xcre, fO1101iIr-,;
turn tc regular antIve full-ti— Wlt',-, PrAicyhC)IcIaE-C
sequF nt t0 of during whic.1-i the r;DVered
r, ,t been Mnnt (W,a"e V vsaQlj*I front such re-
gZar =Uya fuQ.vme woK7 for :nis than throw MYS; Or
(5) ai"noYnr or rZoe aducHon; or
(6) a disesFe wr d=Aer, except that subject. 0 tM�
anj exleptLow of thi, llrr.4.t�d
will be payatl for total disability chit tr a mental dlsea3u r
*
disa"er as provtc--d in , A). o,, (D)
if the cantal dismse or diz;,)r,:;e-. rep ults in the
of the drab. -., pe2s-n in a legally constitatal Tent-I
no' spl :al, as her& naHer Q! fl."eJ, be.nafits Hill be p-,— �,Ic-
for. pr,rt—�n A tha peNn of 11-sab'.1ity wfti'--;-'
with the ccnllnew t of the in su,--,'n
hospital; pn.:-,-i(! d, n-; -ail1 be
payable for arj and all -ol-ifiner.ent
iii td_ the exp'_`rat.--)n of (I-) dULing aqF cny Pe" Of d's-
ability, a three Mimth VAN WIlowln.- t�-.e iast day of
the team of any pr-ececli.rig conflnement for which
the disabled person Is entitled to benefits in accordance
GT-T-D-623 60" s.
fA)
10. The premium. ^ha.rges du. on a premi.im, &ie date £or the coverage
providal by this merit AEz- eemen; is the ate Yee $'0u o° Lchedule
Amount then in effect multi +lied by one - hundredth n_' the
Schoduls Ar.ount i ;hat is In force under bls Benefit Ag, ^eeme. on the
premium due date. If tale p :emium-.s sre pa.Ta'ble Other than cr. a tAort..-
ly basis, each premitun after the first will include -a pro rata ;d-
_Justme,t based uper. the completed months.of couera.ce for insur -fee
placed in effect and _!nsura.r_ce ter::inated during the prec -eding ,e-
miura period.
`t'ha initial rate Pe--'- Y6100 of Schedule Amount will i•e
the pc der by she Company.
if ^' ve. 0 _. _ 11. emilun charges zhal?. not be nadc with- re!3pt -c': to `- pe -
N
Premawn son oil any preen um due date that occurs while the cc ve_ %d r�_r, �� 1s�
M.az,ges disabled and entitled to recel.ve `,,mefit; t:rder ti,is Bert- ' t -R— --e-
ment after the expiration of `-?:e applicable
GIaD -623 tic u
fig)
Application is hereby made
•.
to THE MUTUAL BENEFIT LIFE INSURANCE COMPANY
NEWARK, NEW JERSEY
by THE A. B. C. COMPANY
or group policy no. G 0000 -5
This application is executed in duplicate, one counterpart being attached to said
policy and the other being returned to The Mutual Benefit Life Insurance Company.
It is agreed that this application supersedes any previous application for said
policy.
The number of lives to be insured upon the effective date of the policy is 10
or more, and the number of lives to be insured upon the effective date of the
policy is 90% of those then eligible for insurance.
THE A. B. C. COMPANY_ _
(Full or Corporate Name of Applicant)
COPY
By John Doe, President
(Signature and Title)
Signed at Newark, New Jersey pate__ July 8, ____1967
Witness John Smith
(To be signed by Resident Agent where required by law)
This copy is to remain attached to the policy.
GPA-59
R 232OG (2-59)