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RFP
NUMBE CONT CTO AMO ,, T
6808 Symetra Life Insurance Company $3,726,500
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approval,
The motion to approve this ordinance was made by _�� �- �„m���'� ��r ��t�w`��� �.�,� �,� ,t�'w and seconded by
����.-� ��.<C��'� � , th� c��di�ar��e �ras pass�d �r�d app�rs�r�d by th� f��lc�vvi��
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vote � - ,d ] :
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Aye ay
Abstain Absent
✓
�, ... ,.�........ _t GV10�
PASSED AND APPROVED this the � day of ��,�� �.�(,m � ny
� f� �
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�f l� 1� �% ��� ..s........... �.mm.
�.
.��. ��°� I"�, MAYOR
ATTEST:
JENNIFER WALTERS, CITY SECRETARY
������
BY: ���°" �, �� ��� . � !���
,. �_
� ,��'���.,, �� -�.-. �, = .��,_ ���
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APPROVED AS TO LEGAL FORM:
AARON LEAL, CITY ATTORNEY
BY: �C � ��u�l--t-iU�2 hC,
DocuSign Envelope ID: 183A61BD-007D-406C-A870-C415E6DBB3CB
5ƚĭǒƭźŭƓ /źƷǤ /ƚǒƓĭźƌ ƩğƓƭƒźƷƷğƌ /ƚǝĻƩƭŷĻĻƷ
CźƌĻ bğƒĻ
tǒƩĭŷğƭźƓŭ /ƚƓƷğĭƷ
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tźŭŭǤ .ğĭƉ hƦƷźƚƓ
/ƚƓƷƩğĭƷ 9ǣƦźƩğƷźƚƓ
hƩķźƓğƓĭĻ
DocuSign Envelope ID: 183A61BD-007D-406C-A870-C415E6DBB3CB
Symetra Life Insurance Company
777 108th Avenue NE, Suite 1200
Bellevue, Washington 98004-5135
Application for Group Insurance
City of Denton
Name of Applicant:
901 Texas Street # A
Address:
(Street)
DentonTX76209
(City) (State) (Zip)
applies to Symetra Life Insurance Company, for:
4
Group Short Term Disability Insurance
4
Group Long Term Disability Insurance
4
Group Term Life Insurance
If Symetra Life Insurance Company (Symetra) approves this application, the policy(ies) indicated above
will be issued. The applicant agrees that by signing this application it accepts the policy issued pursuant
to the proposal dated _________________________.July 19, 2018 (Denton #6808)
This application supersedes any previous application.
Any person who, with intent to defraud or knowing he/she is facilitating a fraud against an
insurer, submits an application or files a claim containing a false or deceptive statement may be
guilty of insurance fraud.
Signed at (City) , (State)
Date signed:
THISAGREEMENTHASBEENBOTH
City of Denton
REVIEWESANDAPPROVED
astofinancialandoperationalobligations
andbusinessterms
_____________________________
By
SIGNATUREPRINTEDNAME
_________________________________
Title
TITLE
_________________________________
DEPARTMENT
Agent/Producer Name (printed)
APPROVEDASTOLEGALFORM:
Agent/Producer Signature
AARONLEAL,CITYATTORNEY
Resident Licensed Agent/Producer where required by law
BY:___________________________
ATTEST:JENNIFERWALTERS,CITYSECRETARY
by:__________________________________________
Instructions: (1) Sign and return to Symetra.
(2) Retain copy with your policy.
®
Symetra is a registered service mark of Symetra Life Insurance Company.
LGC-10033 04/12
DocuSign Envelope ID: 183A61BD-007D-406C-A870-C415E6DBB3CB
777 108th Avenue NE, Suite 1200 | Bellevue, WA 98004-5135
Mailing Address: Benefits Division | PO Box 34690 | Seattle, WA 98124-1690
Phone 1-800-426-7784
CityofDenton
01-017863-00
DocuSign Envelope ID: 183A61BD-007D-406C-A870-C415E6DBB3CB
CityofDenton
01-017863-00
DocuSign Envelope ID: 183A61BD-007D-406C-A870-C415E6DBB3CB
Symetra Life Insurance Company
Claims Department Mailing Address:
PO Box 1230 | Enfield, CT 06083
Phone 1-877-377-6773 | Fax 1-877-737-3650 | TTY/TDD 1-800-833-6388
Symetra Life Insurance Company
Tax Services Agreement
Policyholder:
CityofDenton
Policy(ies):
1/1/201901-017863-00
4
01-017863-00
1/1/2019
4
Tax Services Effective Date:January1,2019
Policyholder Tax Identification Number (TIN):
A.STANDARD TAX SERVICES
B.SUPPLEMENTAL TAX SERVICES
DocuSign Envelope ID: 183A61BD-007D-406C-A870-C415E6DBB3CB
C.HOW TAX SERVICES APPLY TO YOUR LOCATIONS, DIVISIONS, OR EMPLOYEE CLASSES
4
GENERALPROVISIONS
Term
ChangingSelected Tax Services
Accurate and TimelyInformation
Reporting
Hold Harmless
DocuSign Envelope ID: 183A61BD-007D-406C-A870-C415E6DBB3CB
6.Pricing for Selected Tax Services
7.Entire Agreement
DocuSign Envelope ID: 183A61BD-007D-406C-A870-C415E6DBB3CB
Symetra Life Insurance Company
Claims Department Mailing Address:
PO Box 1230 | Enfield, CT 06083
Phone 1-877-377-6773 | Fax 1-877-737-3650 | TTY/TDD 1-800-833-6388
Appendix A to Tax Services Agreement
Supplemental STD Services
W-2 SERVICES(select one)
authorize
decline
If You decline W-2 services, STD FICA Match Service may not be selected below.
STD FICA MATCH SERVICE (select one)
authorize
W-2 Services must be selected above if You authorize STD FICA Match Services.
decline
DocuSign Envelope ID: 183A61BD-007D-406C-A870-C415E6DBB3CB
Symetra Life Insurance Company
Claims Department Mailing Address:
PO Box 1230 | Enfield, CT 06083
Phone 1-877-377-6773 | Fax 1-877-737-3650 | TTY/TDD 1-800-833-6388
Appendix A to Tax Services Agreement
Supplemental LTD Services
W-2 SERVICES(select one)
authorize
decline
If You decline W-2 services, LTDFICA Match Service may not be selected below.
LTD FICA MATCH SERVICE (select one)
authorize
W-2 Services must be selected above if You authorize LTD FICA Match Services.
decline
DocuSign Envelope ID: 183A61BD-007D-406C-A870-C415E6DBB3CB
Symetra Life Insurance Company
Claims Department Mailing Address:
PO Box 1230 | Enfield, CT 06083
Phone 1-877-377-6773 | Fax 1-877-737-3650 | TTY/TDD 1-800-833-6388
Appendix B to Tax Services Agreement
Listing of all Locations, Divisions and/or Classes that will have Different Tax Services
DocuSign Envelope ID: 183A61BD-007D-406C-A870-C415E6DBB3CB
Exhibit
Senate Bill 252 -Government Code 2252
CERTIFICATION
I, ______________________________________________, the undersigned
representative of ________________________________________________
(Company or business name) being an adult over the age of eighteen (18) years of
age, pursuant to Texas Government Code, Chapter 2252, Section 2252.152 and
Section 2252.153, certify that the company named above is not listed on the
website of the Comptroller of the State of Texas concerning the listing of
companies that are identified under Section 806.051, Section 807.051 or Section
2253.153. I further certify that should the above-named company enter into a
contract that is on said listing of companies on the website of the Comptroller of
the State of Texas which do business with Iran, Sudan or any Foreign Terrorist
Management Department.
___________________________________
Name of Company Representative (Print)
________________________________
Signature of Company Representative
_________________________________
Date
DocuSign Envelope ID: 183A61BD-007D-406C-A870-C415E6DBB3CB
Exhibit
House Bill 89 - Government Code 2270
VERIFICATION
I, _______________________________________________, the undersigned
representative of ______________________________Company or Business name
(hereafter referred to as company), being an adult over the age of eighteen (18)
years of age, verify that the company named-above, under the provisions of
Subtitle F, Title 10, Government Code Chapter 2270:
1. Does not boycott Israel currently; and
2. Will not boycott Israel during the term of the contract the above-named
Company, business or individual with City of Denton.
Pursuant to Section 2270.001, Texas Government Code:
1.
with, or otherwise taking any action that is intended to penalize, inflict
economic harm on, or limit commercial relations specifically with Israel, or
with a person or entity doing business in Israel or in an Israeli-controlled
territory, but does not include an action made for ordinary business
purposes; and
2. -profit sole proprietorship, organization,
association, corporation, partnership, joint venture, limited partnership,
limited liability partnership, or any limited liability company, including a
wholly owned subsidiary, majority-owned subsidiary, parent company or
affiliate of those entities or business associations that exist to make a profit.
___________________________________
Name of Company Representative (Print)
________________________________
Signature of Company Representative
_________________________________
Date
DocuSign Envelope ID: 183A61BD-007D-406C-A870-C415E6DBB3CB
Exhibit
CONFLICT OF INTEREST QUESTIONNAIRE - FORM CIQ
For vendor or other person doing business with local governmental entity
This questionnaire reflects changes made to the law by H.B. 23, 84th Leg., Regular Session.
This questionnaire is being filed in accordance with Chapter 176, Local Government Code, by a vendor who has a business relationship as
defined by Section 176.001(1-a) with a local governmental entity and the vendor meets requirements under Section 176.006(a).
By law this questionnaire must be filed with the records administrator of the local government entity not later than the 7th business day after
the date the vendor becomes aware of facts that require the statement to be filed. See Section 176.006(a-1), Local Government Code.
A vendor commits an offense if the vendor knowingly violates Section 176.006, Local Government Code. An offense under this section is a
misdemeanor.
Name of vendor who has a business relationship with local governmental entity.
1
2
Check this box if you are filing an update to a previously filed questionnaire.
th
(The law requires that you file an updated completed questionnaire with the appropriate filing authority not later than the 7 business
day after the date on which you became aware that the originally filed questionnaire was incomplete or inaccurate.)
3
Name of local government officer about whom the information in this section is being disclosed.
Name of Officer
This section, (item 3 including subparts A, B, C & D), must be completed for each officer with whom the vendor has an employment or other business relationship
as defined by Section 176.001(1-a), Local Government Code. Attach additional pages to this Form CIQ as necessary.
A. Is the local government officer named in this section receiving or likely to receive taxable income, other than investment income, from the vendor?
Yes No
B. Is the vendor receiving or likely to receive taxable income, other than investment income, from or at the direction of the local government officer
named in this section AND the taxable income is not received from the local governmental entity?
Yes No
C. Is the filer of this questionnaire employed by a corporation or other business entity with respect to which the local government officer serves as an
officer or director, or holds an ownership of one percent or more?
Yes No
D. Describe each employment or business and family relationship with the local government officer named in this section.
4
I have no Conflict of Interest to disclose.
5
Signature of vendor doing business with the governmental entity Date
Certificate Of Completion
Envelope Id: 183A61BD007D406CA870C415E6DBB3CBStatus: Completed
Subject: Please DocuSign: City Council Contract 6808 - Supplemental Life and Disability Insurance
Source Envelope:
Document Pages: 13Signatures: 14Envelope Originator:
Certificate Pages: 6Initials: 0Cindy Alonzo
AutoNav: Enabled901B Texas Street
EnvelopeId Stamping: EnabledDenton, TX 76209
Time Zone: (UTC-08:00) Pacific Time (US & Canada)Cynthia.Alonzo@cityofdenton.com
IP Address: 129.120.6.150
Record Tracking
Status: OriginalHolder: Cindy AlonzoLocation: DocuSign
10/10/2018 8:27:41 AM Cynthia.Alonzo@cityofdenton.com
Signer EventsSignatureTimestamp
Cindy AlonzoSent: 10/10/2018 8:32:29 AM
Completed
cynthia.alonzo@cityofdenton.comViewed: 10/10/2018 8:32:36 AM
Senior BuyerSigned: 10/10/2018 8:34:04 AM
Using IP Address: 129.120.6.150
City of Denton
Security Level: Email, Account Authentication
(None)
Electronic Record and Signature Disclosure:
Not Offered via DocuSign
Mack ReinwandSent: 10/10/2018 8:34:07 AM
mack.reinwand@cityofdenton.comViewed: 10/10/2018 8:39:31 AM
City of DentonSigned: 10/10/2018 8:39:41 AM
Security Level: Email, Account Authentication
Signature Adoption: Pre-selected Style
(None)
Using IP Address: 129.120.6.150
Electronic Record and Signature Disclosure:
Not Offered via DocuSign
Harry MontiSent: 10/10/2018 8:39:43 AM
Harry.Monti@symetra.comViewed: 10/10/2018 12:59:19 PM
SVPSigned: 10/10/2018 1:04:19 PM
Symetra Life Insurance Company
Signature Adoption: Pre-selected Style
Security Level: Email, Account Authentication
Using IP Address: 64.74.106.164
(None)
Electronic Record and Signature Disclosure:
Accepted: 10/10/2018 12:59:19 PM
ID: 825bb7e1-e248-48a6-9a5f-4f5585b10346
Carla RomineSent: 10/10/2018 1:04:23 PM
Carla.Romine@cityofdenton.comViewed: 10/10/2018 2:00:50 PM
Human Resources DirectorSigned: 10/10/2018 2:10:37 PM
Security Level: Email, Account Authentication
Signature Adoption: Pre-selected Style
(None)
Using IP Address: 129.120.6.150
Electronic Record and Signature Disclosure:
Accepted: 10/10/2018 2:00:50 PM
ID: 6e71674f-6317-43fe-9c29-6c9f4b10dc44
Signer EventsSignatureTimestamp
Tabitha MillsopSent: 10/10/2018 2:10:40 PM
Completed
tabitha.millsop@cityofdenton.comViewed: 10/17/2018 6:32:14 AM
City of DentonSigned: 10/17/2018 6:32:58 AM
Using IP Address: 129.120.6.150
Security Level: Email, Account Authentication
(None)
Electronic Record and Signature Disclosure:
Not Offered via DocuSign
Todd HilemanSent: 10/17/2018 6:33:03 AM
Todd.Hileman@cityofdenton.comViewed: 10/17/2018 6:59:58 AM
City ManagerSigned: 10/17/2018 7:00:17 AM
City of Denton
Signature Adoption: Pre-selected Style
Security Level: Email, Account Authentication
Using IP Address: 129.120.6.150
(None)
Electronic Record and Signature Disclosure:
Accepted: 7/25/2017 9:02:14 AM
ID: 57619fbf-2aec-4b1f-805d-6bd7d9966f21
Jennifer WaltersSent: 10/17/2018 7:00:21 AM
jennifer.walters@cityofdenton.comViewed: 10/18/2018 1:11:06 PM
City SecretarySigned: 10/18/2018 1:11:43 PM
City of Denton
Signature Adoption: Pre-selected Style
Security Level: Email, Account Authentication
Using IP Address: 129.120.6.150
(None)
Electronic Record and Signature Disclosure:
Not Offered via DocuSign
In Person Signer EventsSignatureTimestamp
Editor Delivery EventsStatusTimestamp
Agent Delivery EventsStatusTimestamp
Intermediary Delivery EventsStatusTimestamp
Certified Delivery EventsStatusTimestamp
Carbon Copy EventsStatusTimestamp
Sherri ThurmanSent: 10/10/2018 8:34:06 AM
sherri.thurman@cityofdenton.com
City of Denton
Security Level: Email, Account Authentication
(None)
Electronic Record and Signature Disclosure:
Not Offered via DocuSign
Jane RichardsonSent: 10/17/2018 6:33:01 AM
jane.richardson@cityofdenton.comViewed: 10/18/2018 1:15:31 PM
Assistant City Secretary
City of Denton
Security Level: Email, Account Authentication
(None)
Electronic Record and Signature Disclosure:
Not Offered via DocuSign
Carbon Copy EventsStatusTimestamp
Jennifer BridgesSent: 10/18/2018 1:11:48 PM
jennifer.bridges@cityofdenton.com
Procurement Assistant
City of Denton
Security Level: Email, Account Authentication
(None)
Electronic Record and Signature Disclosure:
Not Offered via DocuSign
Jane RichardsonSent: 10/18/2018 1:11:49 PM
jane.richardson@cityofdenton.com
Assistant City Secretary
City of Denton
Security Level: Email, Account Authentication
(None)
Electronic Record and Signature Disclosure:
Not Offered via DocuSign
Scott PayneSent: 10/18/2018 1:11:51 PM
Scott.Payne@cityofdenton.com
Security Level: Email, Account Authentication
(None)
Electronic Record and Signature Disclosure:
Not Offered via DocuSign
Peachy KentSent: 10/18/2018 1:11:53 PM
Peachy.Kent@symetra.com
Security Level: Email, Account Authentication
(None)
Electronic Record and Signature Disclosure:
Not Offered via DocuSign
Notary EventsSignatureTimestamp
Envelope Summary EventsStatusTimestamps
Envelope SentHashed/Encrypted10/18/2018 1:11:53 PM
Certified DeliveredSecurity Checked10/18/2018 1:11:53 PM
Signing CompleteSecurity Checked10/18/2018 1:11:53 PM
CompletedSecurity Checked10/18/2018 1:11:53 PM
Payment EventsStatusTimestamps
Electronic Record and Signature Disclosure
ELECTRONIC RECORD AND SIGNATURE DISCLOSURE
From time to time, City of Denton (we, us or Company) may be required by law to provide to
you certain written notices or disclosures. Described below are the terms and conditions for
providing to you such notices and disclosures electronically through your DocuSign, Inc.
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If you elect to receive required notices and disclosures only in paper format, it will slow the
speed at which we can complete certain steps in transactions with you and delivering services to
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To advise City of Denton of your new e-mail address
To let us know of a change in your e-mail address where we should send notices and disclosures
electronically to you, you must send an email message to us at melissa.kraft@cityofdenton.com
and in the body of such request you must state: your previous e-mail address, your new e-mail
address. We do not require any other information from you to change your email address..
In addition, you must notify DocuSign, Inc to arrange for your new email address to be reflected
in your DocuSign account by following the process for changing e-mail in DocuSign.
To request paper copies from City of Denton
To request delivery from us of paper copies of the notices and disclosures previously provided
by us to you electronically, you must send us an e-mail to purchasing@cityofdenton.com and in
the body of such request you must state your e-mail address, full name, US Postal address, and
telephone number. We will bill you for any fees at that time, if any.
To withdraw your consent with City of Denton
To inform us that you no longer want to receive future notices and disclosures in electronic
format you may:
i. decline to sign a document from within your DocuSign account, and on the subsequent
page, select the check-box indicating you wish to withdraw your consent, or you may;
ii. send us an e-mail to purchasing@cityofdenton.com and in the body of such request you
must state your e-mail, full name, IS Postal Address, telephone number, and account
number. We do not need any other information from you to withdraw consent.. The
consequences of your withdrawing consent for online documents will be that transactions
may take a longer time to process..
Required hardware and software
Operating Systems: Windows2000? or WindowsXP?
Browsers (for SENDERS): Internet Explorer 6.0? or above
Browsers (for SIGNERS): Internet Explorer 6.0?, Mozilla FireFox 1.0,
NetScape 7.2 (or above)
Email: Access to a valid email account
Screen Resolution: 800 x 600 minimum
Enabled Security Settings:
Allow per session cookies
Users accessing the internet behind a Proxy
Server must enable HTTP 1.1 settings via
proxy connection
** These minimum requirements are subject to change. If these requirements change, we will
provide you with an email message at the email address we have on file for you at that time
providing you with the revised hardware and software requirements, at which time you will
have the right to withdraw your consent.
Acknowledging your access and consent to receive materials electronically
To confirm to us that you can access this information electronically, which will be similar to
other electronic notices and disclosures that we will provide to you, please verify that you
were able to read this electronic disclosure and that you also were able to print on paper or
electronically save this page for your future reference and access or that you were able to
e-mail this disclosure and consent to an address where you will be able to print on paper or
save it for your future reference and access. Further, if you consent to receiving notices and
disclosures exclusively in electronic format on the terms and conditions described above,
please let us know by clicking the 'I agree' button below.
By checking the 'I Agree' box, I confirm that:
I can access and read this Electronic CONSENT TO ELECTRONIC RECEIPT OF
ELECTRONIC RECORD AND SIGNATURE DISCLOSURES document; and
I can print on paper the disclosure or save or send the disclosure to a place where I can
print it, for future reference and access; and
Until or unless I notify City of Denton as described above, I consent to receive from
exclusively through electronic means all notices, disclosures, authorizations,
acknowledgements, and other documents that are required to be provided or made
available to me by City of Denton during the course of my relationship with you.