HomeMy WebLinkAboutRESOLUTION - 102-80 - 10/28/1980 - HEALTH INSURANCE PLAN AGRMT/HMORESOLUTIOIu S10. 102-80
A RESOLUTION AUTHORIZING THE VILLAGE PRESIDENT TO SIGN AN AGREEMENT TO
MAKE THE HEALTH ASSURANCE PLAN HEALTH OPTION AVAILABLE TO FULL TIME EMPLOYEES
K01�T, T11EREPORE, BE IT RESOLVED by the President and Board of Trustees
of the Village of Elk Grove Village, Counties of Cook and DuPage, State
of Illinois:
Section 1. That the Village President be and is hereby authorized to
sign the attached documents marked:Group Administration Agreement, thereby
entering into an agreement with the Health Assurance Plan, Inc.
, a copy of which is attached hereto and made a part
hereof as if fully set forth and the Village Clerk is authorized to
attest said documents upon the signature of the Village President.
Section 2. That this resolution shall be in full force and effect
from and after its passage and approval according to law.
PASSED this 28th
APPROVED this 28th
Attcst:
Fay M. Bishop
Village Clerk
day of October
day of October
, 1980 .
Charles J. Zettek 1
president
1980 .
1-.1
233 N M—
(
—m e+
priaa�.lilinr..� e..Y61An
r NINO
GROUP ADMINISTRATION AGREEMENT
I . It is agreed that applications will be submitted under this Agreement for only the following classifications of persons, subject to the Special Remarks,
if anv, set forth in this Item 1. (check one)
❑ Actively employed persons on the payroll of the Company named as Group Administrator in Item 6 below (or its subsidiaries).
❑ Beneficiaries of the Fund named as Group Administrator in Item 6 below.
❑ Members of the Organization named as Group Administrator in Item 6 below lot its affiliates).
❑ Both members and employees of the Organization named as Group Administrator in Item 6 below (or its affiliates).
Spec,al Remarks:
2. It this Agreement has been accepted by HMO Illinois, Inc., then HMO Illinois, Inc. will accept all properly submitted applications and coverage will
commence as provided in the respective subscription certificates issued pursuant to such applications. The beneficiaries under such certificates shall
collectively constitute the "Group''.
3. On behalf of the members of the Group, and not as agent for HMO Illinois, Inc. the Group Administrator agrees to accept all notices to Group members
from HMO Illinois, Inc. and agrees to remit the then prevailing monthly subscription charges to HMO Illinois, Inc. prior to the provision of any
coverage herein. Except for any portion of such charges which it contributes, the Group Administrator will obtain those charges from the Group
members through payroll withholding or otherwise. HMO Illinois, Inc. shall inform the Group Administrator of any merit or other rate refunds.
and shall pay any such refunds to the Group Administrator unless otherwise directed in writing by the Group Administrator.
4. The determination by HMO Illinois, Inc. shall be conclusive of whether any rate refund is due and the amount thereof, if any. HMO Illinois, Inc. shall
not be liable for any interest on any rates or rate refunds. The Group Administrator agrees to indemnify and hold HMO Illinois, Inc. harmless with
respect to any rate refund paid to the Group Administrator or applied as directed in writing by the Group Administrator.
5. In the area served by HMO Illinois, Inc. there are the following number of people in the classification checked in Item 1 above (subject to the stated
Special Remarks, If any):
(a) No Illinois Employees Full Time
Employee Only
Employee + Dependents
TOTAL
Effective Scheduled
Last Enrollment Enrollmen
Special
6.
Signed by_
Type of Business
7. H.I. Representan
CManager___
Accepted:
Part Time Total
No. Employees Under 65
No. Employees Over 65
Deduction
Date
Effective Date
This Enrollment
New Additions yes ❑
New Group ❑
To The Group No ❑
Group's Single $
Contribution
Toward
Number of
Reemollment ❑
Rate: Family $
Present Members
(Herein called
"Group Administrator") Check One: ❑ Company ❑ Fund ❑ Organization
Group Name
Office Locatio
Title
Type of Certificate
H.I. Representative No. Date
lFar HUD Illinois, loc.) (Title)
Original — Gro...-,-ldrmnistrator (white) First Copy — H.l. Representatite (v elloit)
Date
�etand Comet ( bderntrobroy 1pink)