HomeMy WebLinkAbout2922 (2) 1 RESOLUTION NO. 2 9 2 2
2
A RESOLUTION OF THE CITY COUNCIL OF THE CITY OF AUBURN,
3 WASHINGTON, AUTHORIZING THE MAYOR AND CITY CLERK TO EXECUTE A
4 CONTRACT FOR LONG-TERM CARE INSURANCE FOR 1998-1999 BETWEEN
THE CITY AND ALLIANZ LIFE INSURANCE COMPANY OF NORTH AMERICA
5 COVERING LEOFF I EMPLOYEES AND RETIREES FOR AN AMOUNT NOT TO
EXCEED $200, 000 00 PER YEAR
6
7 THE CITY COUNCIL OF THE CITY OF AUBURN, WASHINGTON, IN A
8 REGULAR MEETING DULY ASSEMBLED, HEREWITH RESOLVES AS FOLLOWS
9 Section 1 . The Mayor and City Clerk of the City of
10 Auburn are hereby authorized to execute a Contract for long-
11 term care insurance for 1998-1999 renewable at the City' s
12 discretion for two (2) years between the City and ALLIANZ LIFE
13 INSURANCE COMPANY OF NORTH AMERICA for long-term care
14 insurance covering LEOFF I employees and retirees, for an
15 amount not to exceed $200 , 000 00 per year A copy of said
16 Contract is attached hereto, designated as Exhibit "A" and
17 incorporated by reference in this Resolution
18 Section 2 The Mayor is hereby authorized to implement
19 such administrative procedures as may be necessary to carry
20 out the directives of this legislation
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Resolution No 2922
March 4, 1998
Page 1
1 DATED and SIGNED this 16th day of March, 1998
2
3
4 CITY OF AUBURN
6 .k�l�
CHARLES A BOOTH
7 MAYOR
8
9 ATTEST
10
11 ./W
12 Danielle E Daskam,
13 City Clerk
14
15
16 APPROVED AS TO FORM
17 ,18
19 r\
Michael J Reynolds,
20 City Attorney
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Resolution No 2922
March 4, 1998
Page 2
Allianz Life Insurance Company of North America I'
Administrative Office: Minneapolis, Canoga aIIZ .,
Administrative Office: 6400 Canoga Avenue
Post Office Box 4243
Woodland Hills, CA 91365-4243
(800) 366-5463
A Stock Company
COMPREHENSIVE LONG TERM CARE POLICY
This policy provides Nursing Care Benefits, Home and Community Based Care Benefits
and other benefits as defined herein, subject to all terms and provisions.
Exhibit "A"
Resolution No. 2922
N-2721-P-WA
Allianz Life Insurance Company of North America
Home Office: Minneapolis,, MN
Administrative Office: 6400 Canoga Avenue
Post Office Box 4243
Woodland Hills, CA 91365-4243
(800)366-5463
A Stock Company
COMPREHENSIVE LONG TERM CARE POLICY
NOTICE TO BUYER. This policy may not cover all of the costs associated with long term care incurred
by the buyer during the period of coverage. The buyer is advised to review carefully all policy limitations.
CAUTION: The issuance of this Long Term Care Insurance Policy is based upon your responses to the
questions on your application. A copy of your application is enclosed. If your answers are incorrect or
untrue, we have the right to deny benefits or rescind your policy. The best time to clear up any questions
is now, before a claim arises! If, for any reason, any of your answers are incorrect, contact us at our
Administrative Office shown above.
This policy provides Nursing Care Benefits, Home and Community Based Care Benefits and other
benefits as defined herein, subject to all terms and provisions. In this policy, Allianz Life Insurance
Company of North America will be referred to as "we", "us", or "our" The insured(s) named in the Policy
Schedule will be referred to as "you" or "your"
THIS POLICY IS NOT A MEDICARE SUPPLEMENT POLICY If you are eligible for Medicare, review
the Medicare Supplement Buyer's Guide available from us.
RENEWAL PROVISION—This policy is guaranteed renewable for life Premiums are subject to change.
You may renew this policy for the rest of your life. To renew, just pay the premium due. It must be paid
on or before the due date or within the grace period. We cannot refuse to renew this policy or place any
restrictions on it if the premium is paid on time We can only change the premium based on the
experience for this policy form and all other similar policy forms in your state of the same or different
policy form number We will give you at least 31 days written notice at your last address shown in our
records before we change your premium.
YOUR 30 DAY RIGHT TO EXAMINE YOUR POLICY— If you are not satisfied with your policy, you may
return it to us or our agent within 30 days after you receive it. We will then refund any premium you have
paid and the policy will be considered to be void from its beginning. An additional 10% of the premium
paid will be added to any refund not made within 30 days after you return this policy
Read this policy carefully. It is a legal contract between you and us.
Utvi Dab
Vice President and Secretary Chairman of the Board, President and CEO
N-2721-P-WA Page 1
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PART 1: INSURING AGREEMENT AND EFFECTIVE DATE
We promise to pay the benefits described in this policy. The payment of these benefits is subject to all
of the definitions, limitations, and provisions of this policy. We make this promise and issue this policy
in consideration of: (1) the statements made in your signed application, a copy of which is attached and
made part of this policy; and (2) payment of the initial premium shown in the Policy Schedule. This policy
takes effect on the Policy Date shown in the Policy Schedule and continues in force until the First Renewal
Date shown in the Policy Schedule. All subsequent renewal periods begin and end at 12:01 A.M. at the
place where you live.
PART 2: DEFINITIONS
A. "Activities of Daily Living" are:
1 Bathing: Washing yourself in a tub, shower or by sponge bath, including the ability to get in and
out of the tub or shower
2. Continence: Voluntarily controlling bowel and bladder function, or in the event of incontinence,
maintaining a reasonable level of personal hygiene (including caring for catheter or colostomy
bag)
3. Dressing: Putting on and taking off all garments you usually wear, including any Medically
Necessary braces or artificial limbs, and fastening and unfastening them.
4 Eating: Consuming food by any means once it has been prepared and made available to you.
5. Toileting: Getting to and from the toilet, getting on and off the toilet and maintaining a reasonable
level of personal hygiene.
6. Transferring: Moving to and from a bed, chair or wheelchair
B. "Adult Day Health Care" means a program of community-based social and health-related services
provided during the day in a.community group setting. The purpose of such programs is to support
frail, impaired elderly or other disabled adults who can benefit from care in a group setting outside
the home.
C. "Alternative Plan.of. Care" means benefits of a medical or non-medical nature that may enable you
to recover at home or in another type of facility. Medical alternatives usually consist of providing
services in an alternative setting. Non-medical alternatives will usually provide for physical changes
such as handicap access; or special lifts or ramps.
D "Assisted Living Facility" means a place which.
1 is licensed under state law to perform the services it is providing, where such licensing is required;
and
2. has at least one trained staff member on duty 24 hours per day; and
3. provides continuous room and board; and
4 provides personal care to residents, including, but not limited to, supervision of or assistance with
the Activities of Daily Living and care or supervision required due to Cognitive Impairment.
N-2721-P-WA Page 5
E. "Cognitive Impairment" means the deterioration or loss of your intellectual capacity which requires
supervision or verbal cueing by another person to protect yourself or others. It is determined by
clinical evidence and standardized tests which reliably measure your impairment in the following
areas:
1 Short or long term memory loss.
2. Your orientation as to person (such as who you are), place (such as your location) and time (such
as day, date and year)
3. Deductive and abstract reasoning.
F "Elimination Period" means the number of days you must receive Nursing Care in a Nursing Care
Facility, or the number of days you must receive Home and Community Based Care, or any
combination of the two before benefits become payable under this policy. The Elimination Period is
required only once under this policy. No future Elimination Period will be required once you have
satisfied the Elimination Period shown in the Benefit Schedule. Days may be accumulated under
separate claims in order to satisfy the total Elimination Period.
G. "Family" means a person's spouse, or the person's or spouse's child, parent, brother or sister,
including the same degrees of relationship as effected or affected by a common law marriage, if
recognized in the state where you reside. A member of your Family may not be an owner, nor in any
way control the operation of a Nursing Care Facility in which you receive care or treatment.
H. "Home and Community Based Care" means the care and services described in this policy which are
performed in a setting outside of a Nursing Care Facility, including, but not limited to your home, a
rest home; a residential care facility; an Assisted Living.Facility; a Hospice Care Facility; an Adult Day
Health Care center; and include any of the following health or medical services: home health aide
services; physical therapy; occupational therapy; speech therapy; respiratory therapy; nutritional
services; medical or social services; and medical supplies or equipment services.
I. "Home Care Agency" means an agency providing medical and nonmedical services to ill, disabled
or infirm persons in their residences. Such services may include: homemaker services; assistance
with the Activities of Daily Living;: and Respite Care services. The Home Care Agency and its
employees must be duly licensed orcertified, where required by law, and acting within the scope of
such license or certification at the time a treatment or service is performed.
J. "Hospice Care" means care and services which: provide palliative care, alleviate the physical,
emotional, social and spiritual discomforts you may experience during the last phases of life due to
a terminal disease; and provide supportive care to your primary caregiver and your Family.
K. "Hospice Care Facility' means a place which:
1 is licensed under state law to perform the services it is providing, where such licensing is required;
and
2. provides Hospice Care.
L. "Medically Necessary" means a treatment, service, or supply which is broadly accepted by the
medical profession as appropriate and essential in the diagnosis or treatment of a sickness or accident
and is based on generally recognized and accepted standards of health care.
M. "Nursing Care" means care which is:
1 skilled, intermediate or custodial nursing care; and
2. recommended by a Physician as part of a plan of care; and
3. performed under the supervision of an R.N.
N-2721-P-WA Page 6
N. "Nursing Care Facility" means a place which:
1 is primarily, engaged in providing professional Nursing Care and related services on an inpatient
basis and is licensed under state law to perform the services it is providing; and
2. is a separate facility or a distinct part of another health care facility; and
3. is under the supervision of a Physician, and
4 provides 24-hour per day nursing care under the supervision of an R.N., and
5. maintains a daily record on each patient.
It is not:
1 a hospital; or
2. a place that primarily treats the mentally ill, drug addicts, or alcoholics; or
3. a rest home, residential care facility, Assisted Living Facility, Hospice Care Facility, boarding home,
home for the aged, community living center, a place that provides domiciliary, retirement or
educational care, or
4 a government or veteran facility or any other facility where the patient is not required to pay
0 "Physician" means a duly licensed practitioner of the healing arts The Physician must be acting
within the scope of his or her license at the time the treatment or service is performed. The Physician
must not be a member of your Family. Nor can the Physician nor any member of the Physician's
Family be an owner, nor in any way control the operation of, a Nursing Care Facility in which you
receive care or treatment.
P "Pre-existing Condition" means a condition for which medical advice or treatment was recommended
by, or received from, a provider of health care services during the 6 months immediately prior to the
effective date of coverage under your policy
Q. "Registered Graduate Professional Nurse (R.N.)"means a duly licensed nurse acting within the scope
of his or her license at the time the treatment or service is performed. The R.N must not be a member
of your Family. Nor can the RN nor any member of the R.N 's Family be an owner, nor in any way
control the operation of, a.Nursing Care Facility in which you receive care or treatment.
R. "Respite Care" means short term care provided in a facility, in the home or in a community-based
program which is designed to relieve the primary caregiver in your home.
PART 3: BENEFIT PROVISIONS
A. ELIGIBILITY FOR THE PAYMENT OF BENEFITS
1 You will be Eligible for NURSING CARE BENEFITS if a Physician recommends that you receive
Nursing Care as part of a plan of care because:
a. It is Medically Necessary; or
b. You are unable to perform one or more Activities of Daily Living without the hands-on
assistance of another person; or
c. You have a Cognitive Impairment.
2. You will be Eligible for HOME AND COMMUNITY BASED CARE BENEFITS if a Physician or R.N.
recommends that you receive Home and Community Based Care as part of a plan of care because.
a. You are unable to perform two or more Activities of Daily Living without the hands-on assistance
of another person; or
b. You have a Cognitive Impairment.
N-2721•P-WA Page 7
B. NURSING CARE BENEFIT
We will pay the Daily Benefit for Nursing Care shown in the Benefit Schedule if:
1 You are Eligible for Nursing Care Benefits; and
2. You are receiving Nursing Care which is recommended by a Physician as being: Medically
Necessary; or required due to your inability to perform one or more Activities of Daily Living without
the hands-on assistance of another person; or required due to your Cognitive Impairment; and
3. You are confined in a Nursing Care Facility and your confinement begins while this policy is in
force; and
4 You have not exceeded the Benefit Period or Maximum Total Lifetime Benefit shown in the Benefit
Schedule; and
5. You have satisfied the Elimination Period shown in the Benefit Schedule; arid
6. You are not receiving payments for any other benefits under this.policy
C HOME AND COMMUNITY BASED CARE BENEFIT
We will pay the Home and Community Based Care Benefit shown in the Benefit Schedule if
1 You are Eligible for Home and Community Based Care Benefits; and
2. You are receiving Home and Community Based Care at least once every 7 days; and
3. You have satisfied the Elimination Period shown in the Benefit Schedule, and
4 You have not exceeded the Home and Community Based Care Benefit Period or Maximum Total
Lifetime Benefit shown in the Benefit Schedule; and
5. You are not receiving payments for any other benefits under this policy.
We will pay
1 100% of your actual expenses incurred up to the Maximum Daily Benefit amount for services
provided by a licensed professional nurse or a licensed physical, respiratory, or occupational
therapist; and
2. 80% of your actual expenses incurred up to the Maximum Daily Benefit amount for
a. Care and services received while you are a resident of an Assisted Living Facility;
b. Adult Day Health Care,.
c. Respite Care, up to a maximum of 14 days per calendar year;
d. Hospice Care while you are confined in a Hospice Care Facility;
e. Services provided by a Home Care Agency, including homemaker services; and
f. Services provided by a speech therapist.
D BED RESERVATION BENEFIT
We will pay the Bed Reservation Benefit shown in the Benefit Schedule if:
1 You are Eligible for Nursing Care Benefits; and
2. You are receiving benefits under this policy for Nursing Care; and
— 3. You require hospitalization while confined in a Nursing Care Facility; and
4 You incur charges to reserve your bed in the Nursing Care Facility during your hospitalization;
and
5. You have not exceeded the Benefit Period or Maximum Total Lifetime Benefit shown in the Benefit
Schedule.
This benefit is payable for a maximum of 14 days per calendar year
N-2721-P-WA Page 8
E. ALTERNATIVE PLAN OF CARE BENEFIT
We will pay the Alternative Plan of Care Benefit if:
1 You are Eligible for Benefits under this policy; and
2. You, your Physician and we agree that an Alternative Plan of Care is: (a) medically acceptable;
and (b) the most cost efficient manner in which to provide benefits for your claim under this policy;
and
3. You have not exceeded the Benefit Period or Maximum Total Lifetime Benefit shown in the Benefit
Schedule; and
4 You have satisfied the Elimination Period shown in the Benefit Schedule;.and
5. You are not receiving payments for any other benefits under this policy.
F WAIVER OF PREMIUM BENEFIT
We will waive the payment of any premiums that become due for the policy and any attached riders
after you have been confined in a Nursing Care Facility for a period of 90 days. The 90 days need
not be consecutive, but must be satisfied during a single claim period. The premium will be waived
according to the mode of payment in effect at the time confinement begins. Premium payments will
again become payable on the next renewal date following the end of your confinement. Once your
confinement ends, any subsequent confinement separated by a period of at least 180 consecutive
days will be considered a new claim period, subject to a new 90 day waiting period for waiver of
premium.
G. PERSONAL CARE ADVISOR
A Personal Care Advisor is available to assist you with questions regarding such matters as:
1 Eligibility for benefits;
2. Appropriate level of care;
3. Availability of facilities and other care and service resources in your area, or
4 Any other questions you may have about a claim for benefits.
You can contact your Personal Care Advisor by calling the toll-free number shown in the Benefit
Schedule.
H. RESTORATION OF BENEFITS
No single claim for benefits will be paid which exceeds the Benefit Period shown in the Benefit
Schedule. However, your Benefit Period will be totally restored if you are not eligible to receive
benefits for aLleast.180 consecutive days.
This provision only applies when the Benefit Period shown in the Benefit Schedule is other than
Lifetime.
I. MAXIMUM TOTAL LIFETIME BENEFIT WHILE COVERED UNDER THIS POLICY
Your Maximum Total Lifetime Benefit is shown in the Benefit Schedule The total of all benefit
payments under your policy and any attached riders may not exceed this amount. Your coverage
will end after the Maximum Total Lifetime Benefit has been paid.
N-2721-P-WA Page 9
J. EXTENSION OF BENEFITS
Termination of this policy will not terminate any benefits payable for any confinement if such
confinement begins while this policy is in force and continues without interruption after termination.
Any benefits payable under this provision are subject to: the duration of the Benefit Period; the
Maximum Total Lifetime Benefit; any applicable Elimination Period and all other provisions of this
policy.
PART 4 EXCLUSIONS AND LIMITATIONS
A. GENERAL EXCLUSIONS
This policy does not cover any loss, illness, accident, medical condition, treatment or services:
1 Due to intentionally self-inflicted injury;
2. Occurring outside of the United States or Canada,
3. Due to attempted suicide while sane or insane;
4 Resulting from chemical dependency;
5. Due to care provided by rest cures and routine physical examinations,
6. Provided in a government facility (unless otherwise required by law), services for which benefits
are available under a governmental program (except Medicaid), any state or federal workers'
compensation, employer's liability or occupational disease law, or any motor vehicle no-fault law;
7 Provided by a member of your immediate Family; or
8. For which no charge is normally made in the absence of insurance.
B. PRE-EXISTING CONDITIONS LIMITATION.
We will not pay benefits for a loss due fo a Pre-existing Condition during the first 6 months after the
effective date of coverage under your policy. However, if a Pre-existing Condition is disclosed on
your application, benefits will be paid for such a loss during the first 6 months after the effective date
of coverage of your policy
PART 5. GENERAL POLICY PROVISIONS
A. ENTIRE CONTRACT; CHANGES — This policy and any attachments, plus the application is the
entire contract between you and us. No agent may change it in any way Only an officer of the
Company can approve a change. Any change must be shown on your policy and approved in writing.
B. TIME LIMIT ON CERTAIN DEFENSES — After 2 years from the date of issue of this policy, no
misstatements, except fraudulent misstatements on the application, will void your policy or be used
-- to deny a claim for a loss incurred after the 2 year period.
After 6 months from the date of issue, we will not reduce or deny any claim under this policy due to
a loss resulting from a condition that existed before the effective date of coverage, regardless of when
such loss begins.
C. GRACE PERIOD — Your policy has a 31 day grace period. If a premium is not paid on or before the
due date, you may pay it during the next 31 days. Your policy will stay in force for this 31 day grace
period.
N-2721-P-WA Page 10
D REINSTATEMENT — Your policy will lapse if the premium is not paid before the end of the grace
period. If we receive evidence satisfactory to us that you have a Cognitive Impairment or loss of
functional capacity, we will reinstate your policy without requiring an application, upon payment of all
past due and unpaid premiums, at any time within 6 months of the date your last premium payment
was due. Otherwise, if we later accept your premium without requiring an application for
reinstatement, that payment will put your policy back in force. If we require an application, we will
give you a conditional receipt for your premium. Your policy will be reinstated upon our approval of
such application or, lacking such approval, on the 45th day following the date of the conditional receipt,
unless we have previously notified you in writing of our disapproval of the application.
The reinstated policy will cover only a loss for sickness incurred or for an injury, sustained after the
date of reinstatement. In all other respects, both you and we shall have the.same rights that existed
just before the due date of the premium in default, subject to any provisions noted on or attached to
the reinstated policy.
E. NOTICE OF CLAIM — You must give us written notice of claim within 30 days after your loss or as
soon as reasonably possible You may give notice or you may have someone do it for you. The
notice should give your name and policy number, which is shown,on the Policy Schedule. The notice
should be mailed to us at our Administrative Office or to one of our agents.
F CLAIM FORMS — When we receive your notice of claim, we will send you forms for filing proof of
loss. If we do not send you these forms in 15 days, you may meet the proof of loss rule by giving us
a written statement of the nature and extent of your loss within the time limit stated in the Proof of
Loss section.
G. PROOF OF LOSS —You must give us written proof of loss, in the case of a claim for loss for which
this policy provides any periodic payment contingent upon continuing loss, within 90 days after the
termination of the period for which we are liable. If it is not reasonably possible to give us this timely
proof, we will not reduce or deny your claim if proof is filed as soon as reasonably possible. In any
event, proof must be furnished within 12 months from the time proof is otherwise required, unless
legal capacity is absent.
H. TIME OF PAYMENT OF CLAIMS — Benefits payable under this policy will be paid as soon as we
receive proper written proof of foss.
I PAYMENTS OF CLAIMS —All benefits will be paid to you or your assignee Any benefits unpaid at
your death may be paid to your estate. If benefits are payable to your estate, we may pay up to
$1,000 to any relative of yours by blood or marriage who we find is entitled to it. Any payment made
in good faith wilf discharge us with regard to such payment.
J. BENEFIT APPEALS — If we deny your claim and do not pay benefits under this policy, you or your
representative may appeal such denial. You or your representative must send us a written request
for an appeal which may include any supporting material. We will review your request and notify you
or your representative of our decision within 30 days of receiving the request.
K. PHYSICAL EXAMINATION —We, at our expense, have the right to have you examined as often as
is reasonable while a claim is pending.
L. LEGAL ACTION — No legal action may be brought to recover on this policy before 60 days from the
date written proof of loss has been given to us as required by this policy No such action may be
brought more than 3 years after the date written proof of loss is given to us.
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M. BENEFICIARY—The Beneficiary will be the person or persons named in the application or changed
by written request to receive any benefit payments due upon your death. The Beneficiary's consent
is not required for this or any other change in the policy, unless the designation of the Beneficiary is
irrevocable. You can change the Beneficiary at any time by giving the Company written notice. A
new Beneficiary designation will be effective on the date you sign the written request for the change.
We will not be liable for any action taken or payment made before we record notice of any Beneficiary
change.
If you designate more than one person as Beneficiary, the interests of all Beneficiaries will be equal
unless your designation specifically provides otherwise. The share of any Beneficiary who does not
survive, shall pass equally to the surviving Beneficiaries, unless your designation specifically provides
otherwise. If no Beneficiary is designated or no Beneficiary survives you, then your estate will be
the Beneficiary.
PART 6. OTHER POLICY PROVISIONS
A. OWNER — The Owner of this policy is the insured unless otherwise provided in the application or
changed by written request. While the insured (or either insured if joint coverage) is living, the Owner
may exercise every right and receive every benefit provided by this policy If an Owner other than
the insured dies while the insured is living, all rights of that Owner shall belong to the Owner's
executors or administrators unless otherwiseprovided.
B. MISSTATEMENT OF AGE — If your age was misstated in the application, all benefits payable will
be those that the premium would have bought at your correct age. Furthermore, if no coverage would
have been provided based on your true age; our liability will be limited to a refund of any premium
paid for such coverage.
C. UNPAID PREMIUM — Any premium due and unpaid or covered by a note or written order may be
deducted from any claim payment payable under this policy.
D CONFORMITY WITH STATE STATUTES —Any provision of this policy, which on its effective date,
is in conflict with the statutes of the state in which you reside on such date, is hereby amended to
conform with the minimum requirements of such statutes.
E. ILLEGAL OCCUPATION.— We are not liable for any loss which occurs while you commit or attempt
to commit a felony. ..Also, we are not liable for any loss while you are engaged in an illegal occupation.
F ASSIGNMENT— No assignment of interest under your policy shall be binding upon us unless the
original or a copy of the assignment is filed with us at our Administrative Office shown on Page 1 of
this policy. We do not assume any responsibility for the validity of an assignment.
G. REFUND OF UNEARNED PREMIUM— Upon your death, we will refund any unearned premium for
this policy on a pro-rata basis, less any claims paid during the current term of this policy We will
make this refund within 30 days of receipt of due proof of your death.
N-2721-P-WA
Page 12
Allianz Life Insurance Company of North America
Home Office: Minneapolis, Allianz
Admi nistrative Office: 6400 Canoga Avenue
Post Office Box 4243
Woodland Hills, CA 91365-4243
(800) 366-5463
A Stock Company
FULL CONTINUATION OF COVERAGE NONFORFEITURE BENEFIT RIDER
This rider is made part of the policy to which it is attached and is applicable only when shown on the Policy
Schedule. It is subject to all provisions, definitions, conditions, exceptions, and limitations Of the policy which do
not conflict with this rider If any conflicts occur, the provisions of this rider will In this rider, Allianz Life
Insurance Company of North America will be referred to as"we", "us", or"our" The insured(s) named in the Policy
Schedule will be referred to as "you" or"your"
We promise to pay the Full Continuation of Coverage Nonforfeiture Benefit as described below We make this
promise in consideration of: (1) the statements made in your signed application; and (2) payment of the premium
for this rider This rider takes effect on the date shown in the Policy Schedule and continues in force until the
policy to which it is attached terminates.
FULL CONTINUATION OF COVERAGE NONFORFEITURE BENEFIT
A. If your policy lapses due to nonpayment of premium:
1 Coverage will continue and benefits will be payable at the daily benefit amounts in effect on the date of
lapse as described in the policy and any attached riders.
2. The total of benefits payable under the policy and any attached riders is equal to the total of premiums
paid for the policy and riders. The number of days remaining for which benefits are payable after lapse is
equal to the total of premiums paid divided by your daily benefit amount on the date of lapse.
3. Any premiums paid which are not paid to you in benefits as continued coverage after lapse will be paid to
your Beneficiary upon your death (last of your deaths under joint coverage).
4 Benefits payable under this provision are subject to the same: Benefit Periods; Maximum Total Lifetime
Benefit; any applicable Elimination Period; and all other provisions of the policy and riders that would have
been in effect had the policy not lapsed. However, no further increases will occur under any Cost of Living
Adjustment Rider, if attached to the policy, and the benefit payable under this provision will be the daily
benefit amount in effect on the date the policy lapses.
B. If your policy lapses due to your death (last of your deaths under joint coverage) and the policy has not pre-
viously lapsed due to nonpayment of premium, the total of premiums paid, with no deduction for benefits al-
ready paid to you, will be paid to your Beneficiary
YOUR 30 DAY RIGHT TO EXAMINE YOUR RIDER
If you are not satisfied with your rider, you may return it to us or our agent within 30 days after you receive it. We
will then refund any premium you have paid and the rider will be considered to be void from its beginning. An
additional 10%of the premium paid will be added to any refund not made within 30 days after you return this rider
Read this rider carefully It is a part of a legal contract between you and us.
WEt4te/LI'L`'.`e■
Vice President and Secretary Chairman of the Board. President and CEO
NI 170(1 nn WA
Allianz Life Insurance Company of North America
Home Office: Mffice: olio, Canoga Administrative Office: 6400 Canoga Avenue
Post Office Box 4243
Woodland Hills, CA 91365-4243
(800)366-5463
A Stock Company
COMPOUND INTEREST COST OF LIVING ADJUSTMENT BENEFIT RIDER
This rider is made part of the policy to which it is attached and is applicable only when shown on the Policy
Schedule. It is subject to all provisions, definitions, conditions, exceptions, and limitations of the policy which do
not conflict with this rider If any conflicts occur, the provisions of this rider will apply-—lb this rider, Allianz Life
Insurance Company of North America will be referred to as"we", "us", or"our"._The insured(s) named in the Policy
Schedule will be referred to as "you" or "you?'
We promise to pay the Compound Interest Cost of Living Adjustment Benefit as described below We make this
promise in consideration of: (1) the statements made in your signed'application;and (2) payment of the premium
for this rider This rider takes effect on the date shown in the Policy Schedule and continues in force until the
policy to which it is attached terminates.
COMPOUND INTEREST COST OF LIVING ADJUSTMENT BENEFIT
On each policy anniversary, we will increase the. Daily Benefit amounts shown in the Benefit Schedule by 5%,
compounded annually Benefits will continue to increase-annually while you are receiving benefits.
YOUR 30 DAY RIGHTTO EXAMINE YOUR RIDER
If you are not satisfied with your rider, you may return it to us or our agent within 30 days after you receive it. We
will then refund any premium you have paid and the rider will be considered to be void from its beginning. An
additional 10% of the premium paid will beadded to any refund not made within 30 days after you return this rider
Read this rider carefully it is a part of a legal contract between you and us.
0 kiwi,
Vice President and Secretary Chairman of the Board, President and CEO
N-2720-R4-WA
G►lJ'op
CHARLES A BOOTH,MAYOR // AUBURN CITY CLERK
Danielle Daskam,City Clerk C 25 West Main, Auburn,WA 98001
Cathy Richardson, Deputy City Clerk Auburn l l City C1erk:(253)931-3039
Tamie Bothell, Records/License Clerk II !!� /Business Registration:(253)931-3007 Fax:(253)288-313'
4Shing��
STATE OF WASHINGTON)
ss.
COUNTY OF KING
I, Danielle Daskam, the duly appointed, qualified City Clerk of the City of Auburn,
a Municipal Corporation and Code City, situate in the County of King, State of
Washington, do hereby certify that the foregoing is a full, true and correct copy of
Resolution No 2922 of the resolutions of the City of Auburn, entitled "RESOLUTION
NO 2922."
I certify that said Resolution No 2922 was duly passed by the Council and
approved by the Mayor of the said City of Auburn on the 16th day of March, 1998
Witness my hand and the seal of the City of Auburn this 29th day of May, 1998
I IPA ��
Danielle Daskam, City Clerk
City of Auburn-
RECORDS MANAGEMENT
ORDINANCE/RESOLUTION DISTRIBUTION
ORDINANCE NO ..-_ - DATE ADOPTED- *6- 9?
RESOLUTION NO. aG02 EFFECTIVE DATE.
RECORDING FILE. CODE BOOK.
DEPARTMENT DISTRIBUTION.
' 'DEPT, ^ ,CONTACT " DATE.
CITIZEN REQUESTS
,NAME ADDRESS' s ' ; DATE
F CLERK\REGORDS\RECFORM