HomeMy WebLinkAboutPROOF OF INSURANCEStandard Online Amendment Request 1 of 1 7/9/2024 9:41 AM
Request for Group Insurance Amendment
Standard Insurance Company
900 SW Fifth Avenue
Portland, OR 97204-1282
Employee Benefits Consultant: Nicholas Sharpe
Employee Benefits Service Representative: Genoa Molden
Employee Benefits Sales and Service Office: Seattle
Policyholder: City of Bremerton
Group Number: 141172
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):
Change Age Reductions for the Member to none.
I request that the amendment become effective on 07/01/2024. 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: Title: \s1\\t1\
Authorized Representative
Print Name: Date: \n1\\d1\
DocuSign Envelope ID: C068D58C-BFF8-4437-A8FC-97247F8BA5A2
Human Resources Mgr.
7/9/2024Charlotte Nelson