HomeMy WebLinkAboutCity of Tamarac Resolution R-89-2791
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Temp. Reso. #5590
A RESOLUTION AWARDING A BID
INSURANCE, BID NO. 89_47 T
EFFECTIVE DATE.
CITY OF TAMARAC, FLORIDA
RESOLUTTON NO. R- 89 - e2_
FOR
AND
GROUP HEALTH
PROVIDING AN
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WHEREAS, bids were advertised in the ForE Lauderdale News/Sun
Sentinel, a newspaper of generaL clrculation in Broward County on
August 24, 1989 and August 31, 1989; and
WHEREAS, bids were opened on September 28, 1989; and
WHEREAS, HUMANA HEALTH CARE is the lowest fully responsive
and responsible bidder.
NOW, THEREFORE, BE IT RESOLVED BY THE COUNCIL OF THE CITY OF
TA}4ARAC, FLORIDA:
SECTION 1: That the bid of HUMANA HEALTH CARE in the
following monthly amounts with funds to be taken from various
departmental accounts whose employees are in the HUMANA HEALTH
CARE, is HEREBY APPROVED:
PAfD BY CITY PAID BY EMPLOYEE
MONTHLY MONTHLY
HUMANA (HMO)
STnsfeFamily
ATTEST:
CITY CLERK
I HEREBY CERTIFY that r have
approved this RESOLUTION asto form.
s117 .18
s236.07
$132.50
$236 .07
-0-
s92.03
NORMAN
MAYOR
RECORD OF COUt{Clt voTE
HUMANA PPO
s ngle -0-
s135 .21Family
SECTION 2: That the appropriate City officials are hereby
authorized to execute any and all contract documents necessary in
connection with awarding of this bid.
SECTION 3: This Resolution shal1 become effective
immediately upon adoption. {
PASSED, ADOPTED AND APPROVED this 3f day o 1989.
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l'), r {or'ur:.''/
L
II,IAYOR
DI$IRIGT I:
D TRET E
DISTIICT 3:
DETRET*
R
CITY ATTORNEY
@ffi"4,
I
/1 ', rl- '4 *-u- -CAROL A. EVANS
Juhana
Plan No.: J
GROUP APPLICATION.
option No.: / ru'L
Humana Medical Plan, lnc
1505 NW'l67th Street
Miami, FL 33169
(hereinafter referred to as the Gompany)
f|'f? et ?
Are any affiliatss or subsidiari€s to be coverod
"ES, Please indicate below
d
ol Applicant
t/fl sole pRopRlEToRSHtp fl pRntruensurp
Ll orneR:
Legal Status L- conponRttorl
5 U(-tll Gor,=.u rn€Li
Nature ol
iLJ/v
f,-- 2y'ct
I ndustrial
No.{1- fo? *c K -fqaot-,llt )€/sz\){?'
Crty Slate
,any Name t] vrs
Name
o
[l suesrornny[-l Rrrtrnrr E suastornRvtr RrrrLlRre
IESSAddress
lf Yes - Carrier Nams
/-E4Gu"
Termination
or previously rn force Group plan?Will this plan covsrage replace any
YES tr r.to
Regular Full-Time active
Coverage after being em
employees are ,
ployed lor the a
e forigible Grou p Such mCoverage.m for heployeesayapplypplicablWaitPeriodheTWaiting(s)Pe fo thng New mEriod(s)ployeesTolal /t FT Employees # Eligible lor Co*rrg"4 o, Covered Employeei , Covered Dependent Units
omployaes? rfygS f ruO
lotPeriod(s)
pr€sent plan
I ruo - tf yES, How
you have r€tired
I ves
any existing group medi.l ffi
many JCves t] rvo - rr vES, How many_
Are relired employees to Oe covereO this group for which you ars making applicalron
al work?
YES, give name, condiiion,
employaes coverage explain.
To nls lotallyyour knowledge,are any employees or
nvEs INo
Ives Eruo
Are you aware any employee or care claims in excess ol $10 In last 3 years namo & reasonE tto
tl NO
lo YES, Amount or o/b of Conllbulion
cogt ol covarage?
the
be the cosl ot o/o oltl
t-l vrs I uo
(z: 12:01 A.M.
Date
$
lhe FIRSTundorth is Group
AdvanceNOTE: Payments
in advance by Em
must be made monthly
OPTIONAL
BENEFITS
fl3 Gx
Visit,t,)
irrtr ruo
&rrn ruo
r .qND_ERSTAND TlllS PL_AN TNCLUDES pARTtCtpAloN
M EDICAL QUALITY COST MANAG EM-ENT FRO-C NNIT,IT'i'
I ELECT TO PROVIDE THE CONTINUATION OF COVERAGE MANDATED BY THE CONSOLIDATEDoMNTBUS BUDGET Rqgglglll41p1 nq! qc.,o_q I lt t_r_iljjen"srnr.ro lHer ai Ncjiborr.ro so,I MAY LosE THE BUSINESS rAX oeoucrrbr'r FoR coNTCrguiioNrs ro rHE HEALTH pLAN.
YES
F PYOU DROVI COBERA CONT UN TtoA N DO CUYOUNBEICOGNNTIEDUI?F SE N lv1U BER MOF EEMBHS
IN ALL COMPONENTS OF THE HUMANA
NTLY HAVE FORMER MEMBERS
Received from this Applicant, a one month deposit of $We, the Company, wifl hold the deposit without obligation u
and an Application for coverag e under a Group Plann is either accepted or rejected lf we accept the Applica-
3nJt2
ntil the A'pplicatiotion, the deposit will be applred to thL, first premium due and payable for the coverage. lf re.jected, cove rage will not become effective"lnd the deposit will be refunded. This receipt is void unless the submitted check (or other instrument)clears the bank and pays thelrst monthly premium in full. Notify us or our representative, if you do not receive the Group Plan contract, or information concerningit, within 45 days after receipt. I certify that I have read and understand all of the information on thethis Group Application
a,riU-989 2/87
the date of this
Dale
reverse side of
is
be
Irealmenldato ol first
R- 81't'71
t rHe EFFECTIVE DATE will be determined by us and will be the latest of : (a) the date this Application is given written approval
ry the Company or (b) any Requested Effective Date not prior to the date the applicant signs this Agreement, provided we
lpprove the Application or (c) the date we establish for coverage to begin, in the event this Application is not accompanied: '' information we need in order to underwrite the coverage. A full first month's payment must be received and the Applica-r- ,0ust be approved in writing by us before the plan becomes effective.
APPLICANT CERTIFIES: That unless we agree otherwise in writing, all persons to be covered, except retirees, dependents
rnd those former members covered under a continuation of benefits, are bona fide employees of the applicant, or of a subsidi-
rry or affiliate listed above. A bona ficle employee is a person who actively works at least 30 irours per week for and is paid
ry the applicant or a covered subsidiary or affiliate in a true employee/employer relationship. The work must be done at therpplicant, subsidiary or affiliate's usual place of business or some other place that is usualforthe employee's particular duties,Ither than the employee's home.
i ( TO PROVIDE INFORMATION: The applicant agrees to furnish all data necessary for the efficient administration of the
lruup coverage provided for the covered employees and dependents, if any, to us.
T lS UNDERSTOOD AND AGREED that none of our agents has the authority to: (a) modify this form; (b)waive the answer
o any question; or (c) bind us in any way by giving or receiving any data which is not written on this form. None of our agentslas the authority to: (a) alter or amend the Group Plan or Plans; or (b) bind us by making any promise or representation.
i-HE APPLICANT DECLARES: That the Applicant's Flepresentative has read the above statement and the answers to all of
he questions are complete and true to the best of his or her knowledge. The Applicant agrees: (1) that this Application is offered
rs an inducement for the Group Coverage applied lor; (2) that this Application will form a part of any contract issued; (3) thatrnly the information on this Application will bind the Company; and (4) that no waiver or charge will bind the Company unless;igned by an Executive Officer of the Company. Group coverage will only be provided Ior persons eligible under the plans issued.
*lurnanh'
No b
GROUP APPLICATION
option No.: C )0
Humana Health lnsurance Co. of Flonda, Inc
/ t6toa e- 8q-2'7 ?
(hereinafter referred to as the Company)
atfiliates or subsidiaries to be covered? l l yES A*o (tf yES, ptease indicate betow)
f] suastorRnvI nrrrttRrE
Zip Codo
Will this plan coverage
{ddraag
fr o L Iin force G
replace anv existinorolp Plan?N
ESo lf Yes,
Carrier 6ruFull-
the
rfor
Time active em pl are eligible for Grou Cove Such eafteremployed for the app cable
rage.
Waiti ng
p
li,
# Covered
Are retired
covered by
u are maki
5 YESENO
e
may
WaitiThe ng
to be
for which
n?
lf YES, give name
and reason
for
Do you
covered
medical
have retired employees
|ffii'existins srouP Dn YES
NO
If YES,
how ff ves'r No
If YES,
how 1/
Are all employees applying forat work?
Are you aware of employee
ol $10,000
any
care claims in excess
Will the oyee be
tr YESDNO (lf NO, explain)
To the best of your knowledge,aro any employees or dependentscurrently totally disabted?trYES NNO
lf YES, give name,condition, prognosis
and date of first
treatment.
or dependent incurri ng healthin the last three ?
empl
butecontri towards
of
required
E IEt
If YES,
Amount or o/o
of Contribution
I UNDERSTAND
MEDICAL OUALI
IF YOU PROVIDE COBFIA CONTIBEING CONTINUED? IF YES, NU
liowards the costof dependent I YESnNo
must
in
OPTIONAL
BENEFITS
THIS PLAN INCLUDES PARTICIPATION IN ALL COMPONENTS OF THE HUMANATY COST MANAGEMENT PROGRAM:M
I-FLEC'I TO PROVIDE ]IE CONTINUATION OF COVERAGE MANDATED BY THE CONSOLIDATEDoMNIBUS BUDGET RF9p.l'Jql!!4{Lo-N 4cr 1c._oi.h.4.1.j ur.roeiiSinND rHAr By Nor DotNG so, IMAY LosE THE BUSINESS TAX DEDUcloii ron Coivrnlri[iror.is ro rHE HEALTH pLAN.
NUATION,
IMBER OF
DO YOU CURR HAVE FORMER MEMBERSMEMBERS
Received from this Applicant, a one month deposit of g d an Application for coverage under a Group plan. We, thelpany, will hold the deposit without obligation until the accepted or rejected. lf we accept the Application, the deposit,, be applied to the first premium due and payable for the coverage.lf rejected, cov0rage will not become effective and the deposit willbe refunded. This receipt is void unless the submitted check (or other instrument) clears the bank and pays the first monthly premiumin full. Notify us or our representative, if you do not receive the Group Plan contract, or information concerning it, within 45 days after
ze1af un
Application is either
Lesar status E coRpoRATloN f] plntruERsHtpI solr PRoPRtEToRSHtp I olnER:
fiuMcr t- Cau4
l-2hlA
ntr SUBSIDIARY
AFFILIATE
Company Nam€
Address
Zip CodsCitySIAIO
wit
for
I above Waiting Periods be waived r YES!NOntan
Requested
Effective
Date
-
@ 12:0'l A.M $
E closedn Advance Payment
is he FIR monthST ly
em undernt Gthisrou
ls (tx
# Eligible foi Coverage # ol Covered Employass
,l-989 4/87
I certify that I have read and un the information on the reverse side of this Group Application.the date of this receipt.
Agent Srgnature Daled at Date
6;",r
I
)aty
If YES,
Amount or o/o
of Contribution
I.IOTE:
be made
dr"E ruo --=-->
I t'tO
---------f
' ' K- ff *7 1
IHE EFFECitVg Onfe will be determined by us and will be the latest of: (a)the date this Apptication is given written approvatry the Company or (b) any Requested Effective Date not prior to the date the applicant signs this Agreement, provided werpprove the Application or (c) the date we establish for coverage to begin, in the event thii Application is not accompaniedinformation we need in order to underwrite the coverage. A full first month's payment must be received and the Applica-ru., rnUSt be approved in writing by us before the plan becomes effective.
\PPLICANT CERTIFIES: That unless we agree otherwise in writing, all persoiis to be covered, except retirees, dependentstnd those former members covered under a continuation of benefits, are bona lide employees of the applicant, or of a subsidi-try or affiliate listed above. A bona fide employee is a person who actively works at least 30 hours per week for and is paidry the applicant or a covered subsidiary or affiliate in a true employee/employer relationship. The work must be done at thetpplicant, subsidiary or affiliate's usual place of business or some other place tirat is usual forthe employee's particular duties,)ther than the employee's honre.
f TO PFIOVIDE INFORMATION: The applicant agrees to furnish all data necessary for the efficient administration of the
Jroup coverage provided for the covered enrployees and dependents, if any, to us.
T lS UNDERSTOOD AND AGREED that none of our agents has the authority to: (a) modify this form; (b) waive the answero any question; or (c) bind us in any way by giving or receiving any data which is not written on rhis form. None of our agentslas the authority to: (a) alter or amend the Group Plan or Plans; or (b) bind us by making any promise or representation.
'HE APPLICANT DECLARES: That the Applicant's Representative has read the above statement and the answers to all ofne questions are complete and true to the best of his or her knowledge. The Applicant agrees: (1) that this Application is offeredrs an inducement for the Group Coverage applied for; (2) that this Application will form a part of any contract issued; (3) thatrnly the information on this Application will bind the Company; and (4)that no waiver or charge wi1 OinO the Company'unless
'igned by an Executive Officer of the Company. Group coverage will only be provided for persons eligible under the plans issued.