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Wghmark Llfe Insurance Compam ' Client services, FIS. 20515
`ffIGH"Kr Highmad We Insurance Compam of Ness fork Request For Group P.O. Box 1840
Highmark Casualer Insurance Company
LIFE &CASUALTY GROUP Highmark Services lompany Insurance Amendment Hertford CT 06144.1848
%-x,77-` 9
Policyholder Name: Indian River County Group Policy Number: 908398 9 9 — 1 q$
As an authorized representative of the Policyholder,
Coverage(s): Retiree Life Insurance
1. 1 request that Highmark Life amend the above Group Policy to make the following change(s):
FROM:
T0:
Retiree Life $10,000
Retiree Life $20,000 (retirees retiring on or after 10/1/99)
There are no changes to the Retiree Life rates as a result to this
amendment request effective 10/1/99.
2. 1 request that the amendment become effective on October 1, 1999
NOTE: The requested effective date must be a current or future date.
3. I understand that the amendment will not become effective unless approved and issued by Highmark Life. I request that the
amendment be approved by Highmark Life subject to Highmark Life's usual underwriting requirements, including, if
applicable, Evidence Of Insurability or a Pre -Existing Condition limitation.
4. I understand that additional information may be required before the amendment can be approved. If the requested change is
based on a union negotiated benefit, a copy of the new Collective Bargaining Agreement is attached.
5. I understand that if a rate change is required, then the new rate must be agreed to by the Policyholder before the amendment
will be approved and issued by Highmark Life. [Note: if a new rate has already been provided, it should be shown on
the reverse side of this form.)
6 1 ram,pct that tha a _ Pn lm m :f _pprcYea b Hig ;rrk Li°^,' -G ;ssucd iu thtr N6iiky iwiguagc cusiomariiy used by
Highmark Life.
7. I understand that any increase in Insurance for a Member who does not meet the Active Work Requirement oil the
scheduled effective date of the amendment will be deferred until the first day after the Member completes one full day of
Active Work.
8. I request that the amendment, if approved and issued by Highmark Life, become effective by its terms without any
further acceptance by the Policyholder, and that a copy of this Request for Group Insurance Amendment form be attached to
and made part of the amendment.
_
Signed By Title: Chairman Date: 07-2 7-9S
enne Macht
For Highmark Life Use Only
Name of Highmark Life employee who prepared form:
HM3408
See Reverse Side
40
*� Supplemental Information: To Be Completed by Highmark Life Agent/Broker
Please be sure the Policyholder clearly understands the change requested and any change in premium rates.
'`- Unilenvrititi
L.' V -W ntfn ter' un g ra�� 1ec� t s.
Are there any changes to rates, lives, and/or volume created by this requested amendment? v Yes _ No
If yes, complete the following information and attach census showing age, sex, and insurance amounts for persons to be added or
dropped.
Life Dep. Life AD&D STD LTD Other
Quoted Rates
Approximate Volume Increase
(Decrease)
Lives Increase (Decrease) _
Proposal prepared by _ Home Office _ Field Office _ None Prepared _ Other:
Is any Evidence Of Insurability required on the effective date? _ Yes _ No If yes, attach forms.
sImportantNotices/Revised Certifiestes
Important Notices will be prepared for most changes. New certificates will be provided if the amendment reduces benefits or if we
decide that the changes are so substantial, complex, or numerous that a new certificate is warranted.
Commissions,:'r.Y
Does this amendment involve a change of broker? _ Yes _ No
Change of Commission Scale?_ Yes _ No If yes, please provide name of broker, address and Commission Scale.
Name:
Address:
City: State Zip Code
Commission Scale:
,::.Hartford Home Office.Maiting Instructions
Do you want the completed amendment mailed to the Policyholder from the Home Office? _ Yes _ No If yes, a
copy will be mailed to the broker's office.
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