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Min 11/04/1980 l 197 Wichita Falls , Texas Memorial Auditorium Building November 4, 1980 Items 1 & 2 The Board of Aldermen of the City of Wichita Falls, Texas, met in regular session on the above date in the Council Room of the Memorial Auditorium Building at 8:30 o'clock A.M. , with the following members present. Kenneth Hill Mayor Marvin Traywick John Hampton, Jr. Carol Russell Aldermen Curtis Smith James B. Thomas Horace 0. Boston Stuart Bach City Manager H. P. Hodge, Jr. City Attorney Gerald Carlson Chief Accounting Officer Wilma J. Thomas City Clerk The invocation was given by James Heckathorn, First Nazarene Church. Mayor Hill recognized a group of students from Heritage Christian Academy. Item 3 Moved by Alderman Thomas that minutes of the meeting held October 21 , 1980, be approved. Motion seconded by Alderman Russell , and carried unanimously. Items 4a - 8d Items 5d, 5e, 5f, 6b, and 7b were removed from the Consent Agenda. Moved by Alderman Traywick that the consent agenda be approved, with the above exceptions. Motion seconded by Alderman Thomas. Item 4a Proposed ordinances were presented approving appropriations for various enterprise funds. i ORDINANCE NO. 3740 AN ORDINANCE MAKING AN APPROPRIATION FROM THE AIRPORT REVENUE FUND TO ACCOUNT NUMBERS LISTED BELOW, AND DECLARING AN EMERGENCY. Ayes : Mayor Hill , Aldermen Traywick, Hampton, Russell , Smith, Thomas, and Boston Nays : None ORDINANCE NO. 3741 AN ORDINANCE MAKING AN APPROPRIATION FROM THE TRANSIT FUND TO ACCOUNT NUMBERS LISTED BELOW, AND DECLARING AN EMERGENCY. Ayes: Mayor Hill , Aldermen Traywick, Hampton, Russell , Smith, Thomas, and Boston Nays: None 198 Item 4a, cont'd. ORDINANCE NO. 3742 AN ORDINANCE MAKING AN APPROPRIATION FROM THE WATER & SEWER FUND TO ACCOUNT NUMBERS LISTED BELOW, AND DECLARING AN EMERGENCY. Ayes : Mayor Hill , Aldermen Traywick, Hampton, Russell , Smith, Thomas, and Boston Nays: None -' Item 5a RESOLUTION NO. 2658 RESOLUTION ACCEPTING FROM TEXAS ELECTRIC SERVICE COMPANY BILL OF SALE , FOR STREET LIGHT SYSTEM USED IN CONVERTING TO HIGH PRESSURE SODIUMY VAPOR LIGHTING SYSTEM. THAT;BE IT RESOLVED BY THE BOARD OF ALDERMEN OF THE CITY OF WICHITA FALLS, TEXAS, That certain Bill of Sale, whereby Texas Electric Service Company conveys to the City of Wichita Falls certain facilities used for the High Pressure Sodium street light system, is hereby accepted, and the City Manager is authorized to pay Texas Electric Service Company the sum of $23,759.00 for such Bill of Sale. Ayes : Mayor Hill , Aldermen Traywick, Hampton, Russell , Smith, Thomas, and Boston Nays : None ✓ Item 5b RESOLUTION NO. 2659 A RESOLUTION AUTHORIZING PURCHASE OF SELECTED INTERNATIONAL BUSINESS MACHINE (IBM) EQUIPMENT. WHEREAS, a cost analysis indicated the City could reduce FY 80/81 IBM equipment cost by approximately $12,000.00 by purchasing 1-3272 Control Unit, 17-3277 CRT Terminals and 1-3286 Printer; and WHEREAS, subsequent annual savings of approximately $28,500.00 will be realized through the useful life of said equipment, expected to be an additional two or three years; and WHEREAS, this action is within terms and conditions of current contractual agreements; and WHEREAS, this purchase action was planned for and sufficient funds are budgeted; NOW, THEREFORE, BE IT RESOLVED BY THE BOARD OF ALDERMEN OF THE CITY OF WICHITA FALLS, TEXAS, THAT: The City Manager is hereby authorized to execute a contract for the purchase of selected equipment from the International Business Machine Corporation, similar to attached contract and not to exceed the amount of $13,804.00. Ayes : Mayor Hill , Aldermen Traywick, Hampton, Russell , Smith, Thomas, and Boston Nays: None Item 5c RESOLUTION NO. 2660 RESOLUTION APPROVING CONTRACT TO MAINTAIN EXISTING INTERNATIONAL BUSINESS MACHINE (IBM) EQUIPMENT CURRENTLY IN USE. r 199 i Item 5c, cont'd. BE IT RESOLVED BY THE BOARD OF ALDERMEN OF THE CITY OF WICHITA FALLS, TEXAS, THAT: A maintenance contract between the City of Wichita Falls and IBM, Inc. for maintenance of equipment purchased in November 1980, similar to attached contract, such contract not to exceed $7 ,000.00 in FY80/81 , is hereby approved, and the City Manager is authorized to execute the same for the City of Wichita Falls. Ayes : Mayor Hill , Aldermen Traywick, Hampton, Russell , Smith, Thomas, and Boston Nays: None Item 5d Discussion was held on approving expenditure of funds for additional core borings for Phase II of the Ringgold reservoir study. A motion was made and seconded for passage of a resolution authorizing an additional cost of $14,000 for this work; however, the motion and second were later withdrawn for further study. Alderman Hampton voiced concern over whether we would lose any impoundment facilities by moving the dam 1500 to 2000 feet back upstream. Dick Manahan, Assistant Director of Public Utilities , stated that there are no tributaries coming into this area. Alderman Thomas was opposed to paying Freese and Nichols an additional $14,000. The memorandum from Joe Smith, Director of Public Utilities, stated that Freese and Nichols wanted to move the dam, as well as a cemetery and a historical home. It was revealed by Mr. Manahan that it was not the recommendation of Freese and Nichols to make these changes, but that it was the insistence of the Public Utilities Department. The Board of Aldermen elected to not take any action at this time, but to bring it back at the next regular meeting. Item 5e A proposed resolution was presented accepting the Activities Center renovation, and authorizing final payment. Alderman Hampton asked if all items have been inspected and signed off? Dane Bennett, Director of Budget and Research, stated that the sprinkler system is under a separate contract, and it is not being approved in this resolution. City Manager Stuart Bach showed the Council the final punch list on all items, except the sprinkler system. RESOLUTION NO. 2661 RESOLUTION ACCEPTING RENOVATION AND NEW CONSTRUCTION OF THE WICHITA FALLS ACTIVITIES CENTER. WHEREAS, the City of Wichita Falls and Hambrick-Craig General Contractors , Inc. , entered into a contract dated December 5, 1978, whereby said contractor agreed to renovate and newly construct the Wichita Falls Activities Center; and, WHEREAS, the renovation and new construction of said improvements has been completed in accordance with the original and amended plans and specifications; and, WHEREAS, Certificate for Payment No. 14 has been submitted on this project, which shows a total amount of work done as $1 ,420,263, of which $1 ,419,246 has been paid, leaving a balance due of $1 ,017. NOW, THEREFORE, BE IT RESOLVED BY THE BOARD OF ALDERMEN OF THE CITY OF WICHITA FALLS, TEXAS, THAT: 200 Item 5e, cont'd. The renovation and new construction of the Wichita Falls Activities Center is hereby accepted by the City of Wichita Falls, and the City Manager is directed to pay to said contractor the balance due as shown above. Moved by Alderman Russell that Resolution No. 2661 be passed. Motion seconded by Alderman Boston, and carried by the following vote. Ayes: Mayor Hill , Aldermen Traywick, Hampton, Russell , Smith, Thomas, and Boston Nays: None Item 5f Discussion was held on a request by C.W.L. Dennis for release of 60 feet of an irrigation easement 100 feet wide near Johnson Road and Mistletoe Drive. Fifty feet had previously been requested and authorized in 1971 by Resolution No. 1225 for a sum of $400; however the transaction was never consumated. Mr. Dennis is now requesting 60 feet. Alderman Hampton inquired why Mr. Dennis is now requesting a different width? City Attorney H. P. Hodge stated that at one time this easement was not underground. Mr. Dennis never did go through with the deal , but he now desires to plat and develop this property, and is requesting 60 feet from the City and Water District No. 2. It is operated by the Water District, and he understands that they have not yet approved it. Moved by Alderman Thomas that this item be postponed until the Water District has time to study it. Motion seconded by Alderman Smith, and carried unanimously. V Item 6a Bids for traffic signal equipment were awarded as follows, for a total amount of $137,519.44. 1 . Trans-Tronics (Ft. Worth) -- Controllers and extender boards--$79,883.50 (This includes $39,882 for an additional six controllers for the 1981 bond program due to the low cost. ) 2. Pinkley and Associates (Oklahoma City)--Brackets and changeable signs-- $2,080.94 3. Doerr Associates of Texas (Arlington)--Poles, Mast arms, brackets, and tester--$31 ,291 .00 4. Signal Engineering Company (Ft. Worth)--Signals, bases, brackets, and pull boxes--$24,264.00 Ayes : Mayor Hill , Aldermen Traywick, Hampton, Russell , Smith, Thomas, and Boston Nays : None Item 6b Only one bid was received for repair and renovation of the Activities Center freight elevator. The bid was from the company who originally installed it. Other elevator companies apparently do not want to work on equipment other than their own. Y .RESOLUTION NO. 2662 RESOLUTION AWARDING CONTRACT TO DOVER ELEVATOR COMPANY FOR REPAIR AND RENOVATION OF THE FREIGHT ELEVATOR AT THE WICHITA FALLS ACTIVITIES CENTER. t 201 Item 6b, cont'd. WHEREAS, the City of Wichita Falls has advertised for bids for the repair and renovation of the freight elevator at the Wichita Falls Activities Center; and, WHEREAS, only one bid was received, that being the bid of Dover Elevator Company in the amount of $27 ,095.62, which is found to be a fair and reasonable bid. NOW, THEREFORE, BE IT RESOLVED BY THE BOARD OF ALDERMEN OF THE CITY OF WICHITA FALLS, TEXAS, THAT: The bid of Dover Elevator Company in the amount of $27,095.62 is hereby accepted, and the City Manager is authorized to execute a contract for the City of Wichita Falls with Dover Elevator Company for the repair and renovation of such freight elevator. Moved by Alderman Hampton that Resolution No. 2662 be passed. Motion seconded by Alderman Smith, and carried by the following vote. Ayes : Mayor Hill , Aldermen Traywick, Hampton, Russell , Smith, Thomas, and Boston Nays: None Item 7a JRESOLUTION NO. 2663 RESOLUTION APPROVING PAYMENT AND ACCEPTING CONSTRUCTION OF HIGH PRESSURE SODIUM STREET LIGHTING. WHEREAS, the City of Wichita Falls and Lloyd Thomas Co. , as contractor, entered into a contract dated September 8, 1980, wherein said contractor agreed to remove certain existing fixtures and to install certain new fixtures; and, WHEREAS, said contractor has completed in accordance with the plans and specifications , the removal of one hundred thirteen (113) old fixtures, and the installation of eighty-eight (88) , new fixtures; and, WHEREAS, the final statement has been submitted for this project, and this final statement shows a total amount of work done as $4,622.60. NOW, THEREFORE, BE IT RESOLVED BY THE BOARD OF ALDERMEN OF THE CITY OF WICHITA FALLS, TEXAS, THAT: The removal of old fixtures and installation of new High Pressure Sodium lighting fixtures is completed, and is accepted by the City of Wichita Falls , and the City Manager is authorized to pay to the contractor the amount due as shown on the final statement. Ayes: Mayor Hill , Aldermen Traywick, Hampton, Russell , Smith, Thomas, and Boston Nays: None Item 7b A proposed resolution was presented approving Change Order No. 1 to the Weeks Park Tennis Center project, and the addition of electrical and plumbing lines to serve the water fountain on the golf course. (This system was destroyed by the tornado. ) RESOLUTION NO. 2664 RESOLUTION APPROVING FIRST CHANGE ORDER TO CONTRACT FOR CONSTRUCTION OF WEEKS PARK TENNIS CENTER. WHEREAS, the City of Wichita Falls and C and R Construction and Management Co. entered into a contract dated April 1 , 1980, for the construction of a tennis 202 Item 7b, cont'd. pro shop, walks, patio, fences, lighting and parking at Weeks Park Tennis area; and, WHEREAS, it is deemed advisable to execute a change order to such contract for the addition of a water fountain on the golf course and the substitution of an electrical heat pump for a gas fired heater, which will increase the amount of said contract by $2,406. NOW, THEREFORE, BE IT RESOLVED BY THE BOARD OF ALDERMEN OF THE CITY OF WICHITA FALLS, TEXAS, THAT: That certain first Change Order to said contract dated April 1 , 1980, with C and R Construction and Management Co. is hereby approved, and the City Manager is authorized to execute the same for the City of Wichita Falls. „,k Moved by Alderman Traywick that Resolution No. 2664 be passed. Motion seconded by Alderman Russell , and carried by the following vote. Ayes : Mayor Hill , Aldermen Traywick, Hampton, Russell , Smith, Thomas, and Boston Nays : None Item 7c ORDINANCE NO. 3743 ORDINANCE ACCEPTING IMPROVEMENTS OF THE SEVEN (7) UNITS OF THE 1979 ASSESSMENT PAVING PROGRAM IN THE CITY OF WICHITA FALLS, TEXAS AS DESIGNATED IN ORDINANCE NO. 3435 DECLARING THE CONTRACT WITH TIMMONS- ANDERSON CORP, WICHITA FALLS, TEXAS FOR THE CONSTRUCTION OF SAID IMPROVEMENTS FULLY COMPLETED AND PERFORMED; DIRECTING THE ISSUANCE, EXECUTION AND DELIVERY OF CERTIFICATES IN EVIDENCE OF SPECIAL ASSESSMENTS LEVIED AFTER GIVING EFFECT TO SUNDRY CREDITS HEREIN AUTHORIZED AND ALLOWED AGAINST SOME OF SAID ASSESSMENTS; DIRECTING THE CITY CLERK TO ENGROSS AND ENROLL THIS ORDINANCE BY COPYING THE CAPTION OF SAME IN THE MINUTE BOOK OF THE BOARD OF ALDERMEN OF THE CITY OF WICHITA FALLS, TEXAS AND BY FILING THE COMPLETE ORDINANCE IN APPROPRIATE ORDINANCE RECORDS OF SAID CITY; AND PROVIDING AN EFFECTIVE DATE. Ayes: Mayor Hill , Aldermen Traywick, Hampton, Russell , Smith, Thomas, and Boston Nays: None Item 8 Minutes of the meetings of the following boards and commissions were received. a. Design Review Commission--September 25, 198o b. Planning Board--October 8, 1980 c. Human Relations Commission--October 23, 1980 d. Centennial Commission--October 15, 1980 Ayes : Mayor Hill , Aldermen Traywick, Hampton, Russell , Smith, Thomas, and Boston Nays : None Item 9a The public hearing was opened on the 1980 annexation program. Director of Planning Roger McKinney explained that most of these tracts have had extensive preliminary plat activity in the area in the last calendar year. He presented pertinent facts concerning Tract I. 203 Item 9a, cont'd. Mrs. Mark Petty, Quincy Road, asked some questions about water service, stating that she and the Weavers do not want to be in the city limits. Mr. Carrol Dunn, Quincy Road, opposed annexation. He also had several comments concerning water service in that area. He cited an example of one man who is outside the city limits who has city water. Mr. McKinney stated that the man put in a private system, and that they do not authorize meters outside the city. Mayor Hill requested that Mr. McKinney give the Council more information on this matter. Tract II was discussed by Roger McKinney. J. D. Avis appeared representing Keith Ranch. He opposed annexation of this ranch land. He mentioned Wilson Manufacturing. The Council pointed out that Wilson Manufacturing requested annexation last year, and that is why the City allowed them to have water, even though they paid for it. Mayor Hill noted that the primary purpose of annexation is for control , although taxes are a part of it. He does not want a long strip. When these people know that they will be taken into the city limits, perhaps they will build within the city limits. He wants our building inspector to be able to control the building in the City of Wichita Falls. Roger McKinney explained the location and features of Tract III. Bill Browning, Attorney, spoke in opposition to annexation of a portion of Tract III, representing Mr. and Mrs. Dan Richardson. Their property lies East of Turtle Creek Road. At the time the Planning Board met, Mr. Richardson was told that the lift station to serve the Tanglewood area would be placed on his property. The lift station is not now going to be placed on his property. The 35-acre tract owned by the Richardsons has no city utilities. He does not believe the City is in a position to provide the necessary services to this area in the three-year period required by state law. He stated that there is no actual growth in this area. The Richardsons have lived there two months, and have no plans to subdivide this land. Mr. Browning noted that the annexation request is based on a townhouse to be built on the bluff. The Richardsons' area has nothing to do with the town- house development. Assistant Director of Public Utilities Dick Manahan stated that if everything that is platted came on the system right now, we would be overloaded on the sewer system. It was noted that this tract of land would not be encircled by the city limits on the north. Alderman Smith stated that he had no problem in considering leaving the Richardson tract out of the annexation process. Tract IV was discussed by Roger McKinney. He stated that it is an area where substantial developments have occured. There has been considerable family- type development in that area since last year. Tom Darling appeared as Senior Vice President of Burke Royalty. He stated that they have water and electricity at their facilities. They maintain their own roads, and have their own sewage system. Ninety-five percent of the buildings on the Jacksboro Highway are fireproof. They look after their own security. Other than taxes, he wonders what the City can furnish to Burke Royalty that they don't now have. He sees no reason for the hopscotching in that area, and requested that the area not be annexed. He later stated that they have an alternative. They can move somewhere else. Bill Gowan, Attorney, represented a majority of the property owners involved in this annexation. He stated that the City should look at the guidelines for property annexation. Platting has nothing to do with survey lines . It is not being annexed prior to or at the beginning of development. He stated that there has been no substantial development of any kind out there since last year except for North of Rathgeber Road. He asked what the citizens out there would get as a result of being annexed? They are presently served by three fire departments. They have their own water system. Five times a night a private police checks their businesses. They utilize private enterprise for trash pickup. They have their own sewer system. The City is already getting some benefits from the sale 204 Item 9a, cont'd. of water to Scotland. These people live here in the City, and pay taxes on their resources. This area was not recommended for annexation by the Planning Board this year. Mr. Gowan further stated that the purpose of annexation is to take the City step by step, and build it out on an orderly basis . There is a time and place for annexation, but it is not here, and not now. Gary Shores appeared as General Manager of Medders Oil Company. They feel their property is solely agriculture. They do not feel that any services provided by the City will be of any benefit to the City. Their property is on the South end of something else. He would like the Council to consider those facts. Mrs. Darnell Kirch stated that her property is located south of the Wichita Speedway. They have septic tanks. They take care of their own trash. They purchase water from Scotland. The majority of the land which will be annexed is not industrial development. Most of it is agricultural . These small industries will not be hurt, but the farmer will be. She opposed being taken into the City of Wichita Falls, stating that she does not want to be a part of the City. Al Vergauwen appeared as the owner of Wichita Speedway. He stated that Wichita Falls gets a lot of recognition in the United States because of the Speedway. If this is taken into the City limits it will close the track down. They have 2000 to 3000 people there every Friday night. Alderman Thomas inquired why it would close? Mr. Vergauwen stated because of the tax base and the noise level . He stated that 90 percent of all racetracks are owned by cities and counties. Frieda Vogtsberger stated that she has a farm located on both sides of the highway. She raises wheat, oats, etc. There are productive farms which will suffer from this tax burden. Louis Scherff appeared for Sam Roddy, stating that he had owned and lived on that place for 52 years. He has his own utilities. He is not in favor of being annexed. Tom Curran stated that he owns property next to Mr. Roddy. They purchased this property several years ago for personal pleasure and business reasons. They have utilities, and cannot see any reason for being in the City. The public hearing was closed. Another hearing will be held at the next council meeting. Alderman Smith left at 11 :00 A.M. , and returned at 11 :45. ✓, Item, 13a — — — — — — — — — Dr. Clifford Burross appeared for the Wichita County Appraisal District. He stated that the Appraisal Board is working together and basically speaking in a unanimous voice. The law authorizing the District provided that cost of operation would be based on the taxes levied. The members of the Board felt very uncomfortable with this. If three-fourths of the jurisdictions agreed, a different method could be used for apportionment. The two jurisdictions which have the best records, and which would cost less to bring in are the City of Wichita Falls and Wichita Falls Independent School District. To follow the avenue provided would penalize the City of Wichita Falls and the Wichita Falls School District. They proposed to use the total number of taxing accounts in all jurisdictions, or use the total parcel method. This proposal was agreed upon by all eight members of the Board. The County said it was unacceptable. Their only option is if three- fourths of the jurisdictions agree on a different method. They cannot change from the way the law was made unless three-fourths agree. Three have turned this down, and this is enough to make it unacceptable. The Board members feel that inequities in the law make the apportionment unfair. City Manager Stuart Bach noted two other methods of apportionment--one by cost accounting and one by a weighted tax account system. Tom Foley, also a member of the Board, stated that the Chairman had done a good job in uniting the members of this Board. If the City has another method they would like to propose, then they would be glad to look at it, but the Appraisal Board cannot take the lead. 205 Item 13a, cont'd. ,- Moved by Alderman Hampton that the City approve the parcel method, as proposed by the Appraisal Board. Motion seconded by Alderman Thomas, and carried unanimously. Mayor Hill turned the meeting over to Mayor Pro tem Thomas at 11 :40 A.M. , when he had to leave. Item 9b The public hearing was opened on hazardous structures. No one desired to be heard. ORDINANCE NO. 3744 ORDINANCE CLOSING HEARING AND FINDING CERTAIN BUILDINGS AND/OR STRUCTURES TO BE DANGEROUS; COMMANDING PROPERTY OWNERS TO REPAIR, VACATE, OR DEMOLISH SAID BUILDING AND/OR STRUCTURES WITHIN THIRTY (30) DAYS OF THE DATE OF THIS ORDINANCE AND DECLARING AN EMERGENCY. Moved by Alderman Hampton that Ordinance No. 3744 be passed. Motion seconded by Alderman Traywick, and carried by the following vote. Ayes: Mayor Pro tem Thomas, Aldermen Traywick, Hampton, Russell , and Boston Nays: None Item l0a A proposed ordinance was presented approving revised rates for Texas Electric Service Company. City Manager Stuart Bach recommended that the Council adopt the rates that would have resulted from the proposal by the rate consultants. This action will protect our right of appeal . City Attorney H. P. Hodge, Jr. stated that several cities have already taken this action, and recommended adoption of the ordinance. ORDINANCE NO. 3745 AN ORDINANCE APPROVING RATE SCHEDULES TO BE CHARGED BY TEXAS ELECTRIC SERVICE COMPANY IN THE CITY OF WICHITA FALLS, TEXAS, PROVIDING FOR AN EFFECTIVE DATE FOR SUCH RATE SCHEDULES, AND PROVIDING CONDITIONS UNDER WHICH SUCH RATE SCHEDULES MAY BE CHANGED, MODIFIED, AMENDED OR WITHDRAWN. Moved by Alderman Traywick that Ordinance No. 3745 be passed. Motion seconded by Alderman Boston. Jack Redding, Manager of Texas Electric, stated that the Touche Ross recommendation is grossly inadequate to meet the needs of his company. The motion carried by the following vote. Ayes : Mayor Pro tem Thomas , Aldermen Traywick, Hampton, Russell , Smith, and Boston Nays : None Item lla Will Griffin appeared as District Manager for Blue Cross/Blue Shield. He stated that the main objective is to try to come up with a system whereby the City would not have to increase dependent costs by 38 percent. He stated that they would trade life coverage for dental coverage at a cost of $22,000. 206 Item lla, cont'd. Alderman Thomas felt that we should increase the payroll deduction for dependents. Alderman Traywick stated that we should revise the benefits in this plan. He recommended Option IIa, stating that the stop-loss is a necessity today. Director of Personnel Janet Hardegree stated that an increased deductible will hurt a lot of our low-paying employees. They would also be hurt by increased rates. Alderman Traywick explained that one reason you need a benefit modification is that you are rewarding the non-users, and not penalizing the users. 'vRESOLUTION NO. 2665 RESOLUTION AUTHORIZING THE CITY MANAGER TO EXECUTE A RENEWAL AND REVISION OF THE CONTRACT BETWEEN THE CITY OF WICHITA FALLS AND BLUE CROSS BLUE SHIELD OF TEXAS FOR EMPLOYEE HEALTH INSURANCE. THAT:BE IT RESOLVED BY THE BOARD OF ALDERMEN OF THE CITY OF WICHITA FALLS, TEXAS, That certain proposal , a copy of which is attached hereto, between the City of Wichita Falls and Blue Cross Blue Shield of Texas, calling for revisions in the health insurance program presently provided to the employees of the City of Wichita Falls is hereby approved, and the City Manager is authorized to execute a contract, in accordance with the proposal and the annual renewals thereof, for the City of Wichita Falls. Moved by Alderman Traywick that Resolution No. 2665 be passed, approving Modification Plan IIa. Motion seconded by Alderman Smith, and carried by the following vote. Ayes : Mayor Pro tem Thomas, Aldermen Traywick, Hampton, Russell , Smith, and Boston Nays: None Item llb A proposed resolution was presented expanding the membership of the Centennial Commission, and authorizing the convener to create, organize, and staff various committees. Alderman Hampton asked what was meant by staffing? City Manager Stuart Bach stated that it was for a consultant to help with the Centennial celebration. J. C. Boyd stated that they are considering a proposal by a consultant (Rogers Company) to coordinate the centennial celebration. The section dealing with staffing was deleted from the resolution. RESOLUTION NO. 2666 RESOLUTION EXPANDING THE MEMBERSHIP OF THE WICHITA FALLS CENTENNIAL COMMISSION AND AUTHORIZING THE CONVENER TO CREATE AND STAFF COMMITTEES TO AID THE COMMISSION IN REALIZING ITS GOALS. WHEREAS, by Resolution No. 2510 the Board of Aldermen of the City of Wichita Falls, Texas, created the Wichita Falls Centennial Commission which was charged with the responsibility of planning activities to celebrate the Wichita Falls Centennial , and the Board of Aldermen deem it necessary to expand the membership of said commission, and to authorize the convener to name and staff various committees which will aid the commission in the performance of its duties. NOW, THEREFORE, BE IT RESOLVED BY THE BOARD OF ALDERMEN OF THE CITY OF WICHITA FALLS, TEXAS, THAT: SECTION 1 . The Wichita Falls Centennial Commission membership is hereby expanded to includ following members: 207 Item llb, cont d. Mrs. Elizabeth Prothro Jim McDonald Paul Latture Dale Terry Dick Waggoner John Mark Hirschi Larry Francell Dr. John G. Barker John T. Gavin Mrs. Ruth Estes Mrs. Delores Jones Moved by Alderman Hampton that Resolution No. 2666 be passed, deleting Section 2. Motion seconded by Alderman Traywick, and carried by the following vote. Ayes : Mayor Pro tem Thomas, Aldermen Traywick, Hampton, Russell , Smith, and Boston Nays : None 'Item llc A proposed resolution was presented authorizing the City Manager to execute a contract for the inventory and appraisal of general fixed assets. Chief Accounting Officer Gerald Carlson explained this proposal . RESOLUTION NO. 2667 RESOLUTION APPROVING CONTRACT WITH MARSHALL AND STEVENS INCORPORATED TO CONDUCT AN INVENTORY AND APPRAISAL OF THE GENERAL FIXED ASSETS OF THE CITY. WHEREAS, Marshall and Stevens Incorporated has submitted to the City of Wichita Falls a proposal dated September 25, 1980, to conduct an inventory and appraisal of the general fixed assets of the City for a fee of $39,000; and, WHEREAS, Marshall and Stevens Incorporated has furnished an alternative proposal whereby City personnel would conduct the inventory of land and equipment, which would reduce the fee from $39,000 to $26,500. NOW, THEREFORE, BE IT RESOLVED BY THE BOARD OF ALDERMEN OF THE CITY OF WICHITA FALLS, TEXAS, THAT: The proposal of Marshall and Stevens Incorporated, dated September 25, 1980, for a fee of $39,000, is hereby accepted, and the City Manager is authorized to execute for the City of Wichita Falls a contract, a copy of which is attached hereto, with Marshall and Stevens Incorporated for such services. Moved by Alderman Hampton that Resolution No. 2667 be passed. Motion seconded by Alderman Russell , and carried by the following vote. Ayes: Mayor Pro tem Thomas, Aldermen Traywick, Hampton, Russell , Smith, and Boston Nays: None Item lld A proposed resolution was presented deferring the conduct of a public hearing concerning electrical and gas utility ratemaking and service standards as required under the Public Utility Regulatory Policies Act of 1978. City Manager Stuart Bach explained the reasons for this deferment. RESOLUTION NO. 2668 RESOLUTION DEFERRING THE CONDUCT OF A PUBLIC HEARING CONCERNING ELECTRICAL AND GAS UTILITY RATEMAKING AND SERVICE STANDARDS AS REQUIRED UNDER THE PUBLIC UTILITY REGULATORY POLICIES ACT OF 1978. WHEREAS, the Public Utility Regulatory Policies Act of 1978 requires that any state agency in Texas, having ratemaking authority with respect to the sale 208 Item lld, cont'd. of electricity, conduct a public hearing and make determination as to whether any of the eleven ratemaking and service standards contained in Section 111 (d) and Section 113 (b) of PURPA should be adopted as a matter of public policy to carry out the stated objectives of PURPA, and requires that each regulatory authority which has ratemaking authority with respect to a gas utility shall conduct a public hearing and make determination respecting the two service standards contained in Section 303 (b) , as to whether these standards should be adopted; and, WHEREAS, the City is a state agency having ratemaking authority and original jurisdiction with respect to electric utility rates, operations and services and gas utility rates, operations and services rendered within the municipal boundaries of the City; and, WHEREAS, the Public Utility Commission of Texas is a state agency having original jurisdiction over electric utility rates, operations and services outside of municipal boundaries, and has exclusive appellate jurisdiction to revenue orders and ordinances of the City pertaining to electric utility rates , operations and services over which the City has original jurisdiction; and, WHEREAS, the Public Utility Commission of Texas has initiated public hearings to consider and determine whether PURPA standards should be adopted as a matter of public policy and said Commission is well equipped to consider and determined such standards. NOW, THEREFORE, BE IT RESOLVED BY THE BOARD OF ALDERMEN OF THE CITY OF WICHITA FALLS, TEXAS, THAT: The conduct of public hearings as required under the Public Utility Regulatory Policies Act of 1978 and the determination as to whether any of the ratemaking and service standards contained in such Act shall be adopted are herewith in the planning stage, but shall be deferred until the Texas Public Utility Commission has developed its own position on each of these standards so that the Board of Aldermen will have the benefit of such Commission's findings and determination, and the benefit of information from other sources. Moved by Alderman Smith that Resolution No. 2668 be passed. Motion seconded by Alderman Boston, and carried by the following vote. Ayes: Mayor Pro tem Thomas, Aldermen Traywick, Hampton, Russell , Smith, and Boston Nays : None Item 12a A proposed resolution was presented awarding the bid for drainage improvements in Lincoln Heights. ` RESOLUTION NO. 2669 RESOLUTION AWARDING CONTRACT FOR THE LINCOLN HEIGHTS DRAINAGE PROJECT OF THE 1980 CAPITAL IMPROVEMENT PROGRAM. WHEREAS, the City of Wichita Falls had advertised for bids for the construction .. of the Lincoln Heights Drainage Project of the 1980 Capital Improvement Program; and, *� WHEREAS, three bids were received, and it is found that the bid of Duke Concrete Construction Company in the amount of $206,835.70 was the best bid received, and should be accepted. NOW, THEREFORE, BE IT RESOLVED BY THE BOARD OF ALDERMEN OF THE CITY OF WICHITA FALLS, TEXAS, THAT: Said bid of Duke Concrete Construction Company in the amount of $206,835.70 is hereby accepted and the City Manager is authorized to execute a contract with Duke Concrete Construction Company for the construction of such improvements. Moved by Alderman Hampton that Resolution No. 2669 be passed. r 209 Item 12a, cont'd. Motion seconded by Alderman Smith, and carried by the following vote. Ayes: Mayor Pro tem Thomas, Aldermen Traywick, Hampton, Russell , Smith, and Boston Nays : None Item 13b Bill McMorries appeared as the City's consultant concerning a rate request submitted by Lone Star Gas Company. He stated that a rate case involves the adjusted value rate base, rate of return, and expenses and income. Dr. Jack Hopper discussed the level of profits a company should be allowed to earn as a bottom line after taxes. He talked about bonds , preferred stock, and common equity. He noted that we are dealing with a monopoly. Wayne Brown spoke on income, and what expenses are incurred in a rate application. They have to use a test year. Expenses have to be annualized and normalized. The test year ended December 31 , 1979. David Liles appeared as Manager of Lone Star Gas Company. He stated that he is confident that this Council 's goal is to have the lowest possible rates to permit Lone Star to obtain a necessary rate of return. He stated that ratemaking is not a simple matter. He noted certain differences in their request and the consultant's recommendations. There is justification for a higher rate of return to be allowed on the common equity. They do not agree with the adjusted value on depreciation. He feels three years is sufficient to recover losses from the tornado. They will work with the Council on a solution to this problem. Moved by Alderman Hampton that the City staff, the consultants, and Lone Star Gas Company negotiate for a suitable agreement, to be brought back to the Council for local disposition. Motion seconded by Alderman Russell , and carried unanimously. An executive session on personnel and legal matters was held at 2:05 P.M. The meeting resumed at 2:20 P.M. (Alderman Russell left at this time. ) Item 13c RESOLUTION NO. 2670 RESOLUTION APPOINTING ONE MEMBER TO THE BOARD OF HEALTH TO SUCCEED LOUIS M. THEIMER, M.D. WHEREAS, by Resolution No. 2244 Louis M. Theimer, M.D. was appointed as a member of the Wichita Falls City-Wichita County Board of Health for a two year term commencing January 1 , 1979 and expiring December 31 , 1980; and, WHEREAS, Dr. Theimer has submitted his resignation from the Board of Health, and the Board of Aldermen of the City of Wichita Falls desire to make an appointment to fill the vacancy on the Board of Health. NOW, THEREFORE, BE IT RESOLVED BY THE BOARD OF ALDERMEN OF THE CITY OF WICHITA FALLS, TEXAS, THAT: Dr. Garland Dean, M.D. is hereby appointed a member of the Wichita Falls City-Wichita County Board of Health for a term of two years, commencing January 1 , 1981 , provided said appointment is duly ratified by the Wichita County Commissioners Court. Moved by Alderman Hampton that Resolution No. 2670 be passed, appointing Dr. Garland Dean to the Board of Health for a term of two years, beginning January 1 , 1981 . Motion seconded by Alderman Smith, and carried by the following vote. ---' ------~~~ -~~`^-~----^--~-~~�-~�~---------- | 210 Item 13c cont'd Ayes: Mayor Pro t8m Thomas, Aldermen TrdywiCk, Hampton, ���t� and BO3t0D Nays : None " The Board of Aldermen dd 'OUrD2d at 2:25 P.M. PASSED AND APPROVED thi u �y O� , 1980. MAYUK ATTEST: �= � CITY CLERK 2 1 t�I +1'Iw—,rAC I til'rTIl,N rlr lA( 11 f.A(IRCIto f n,.,I! %I T'If '41r;NA IIJilt AreF-Ali',I I flint .-1 ,I„- rq��•.�r; �Ir1E5 9 LFy4E CARBONS IN SECTIC,N 2 INTACT UN TIt AFL SIGNATI If1F;Af f IXf n CUSTOMER'S NAME MUST AGREE,SECTIONS 1 AND 2. 418589 International Business Machines Corporation Armonk. New York 10504 ,%greement for Purehase of Installed 11111 1laehines To: Inlernational Business Mae-pines Corporation %grrf•fnrnl No.: Ilraneh Offiee Addre—: Branch Offiee No.: 160 One Summit Ave Fort Worth, Tx 76102 I tf,lnfnrr No.: 9752900 Name allll Address of Coslnnter: Lfferti.e Dille of Ilu„Nttiun: 10/21/80 City of Wichita Falls (►oolltlion t:.flintlion Pall-: 10/31/80 1300 Seventh St Wichita Falls , Tx 76301 Effrrli,r Parr If I'nrrha,r: The CuJomer a{rev, to ptlydla,r:uul Inl,l nalional B11,111e„ \larhiI11- (,(Irllorafilnl 1111\1) h% it- ❑,rr111anre of Ihi \E reenu nt ag,rre, Io ,ell, in arrord:ul(-, Hill) Ihr folio%%ing:term,and rondilion,, fir 11mrhi or,;ou] f.ill Ill r, II>It•II heIfW %%11irh art' tlm% in,lallr,l under all 113\1 lea,e or retltal ag;rr,mmIIl illid in dlf•llo,,,,,iorl of Ihr(:u,lonu•r. l ndt r Ihe,r 11'IIII-and rondili 1n -IIS�I %%ill I) ,It'll Ilia, to the Cu, n IoTer. '._'1 1lrucirle %%arr:ln ,er a1 tl ciee, applirahlr, flit' n1,0-11inr. a1111 :1) a- a%ailahlr, furni-h 11111rr,tnrnrinr ,tall llro�Tranuning ser%ire,.all a,de,rrihed herein. Ilrf•Cu,lonler ag levr If,arrelll Ihr 111:1, inr . \%;o I,ITIIN ,er%irr. girt,, ratnrninR;ul,l lit 1 rmolilinl,,rr- ci,r, ender the term,and roodition, of llli, ;\g trenlefir The CII'Iolnrr fill lhrr agvrre,%%1111 re,l,rr1 lit Ihr TH,l( ne,anti 111 11g,rat"Ill 11 to accent flie for 1) their,elrrtion to arhie%e Ille (:n,lonlrr., inlendrd re11111-, 2) Ifleir u-r Alld 3) [he If -oll,Idlr nrd therefrom. The Gl,tonler al,o ha, Ihr re,l,on,ihilitc for Ihr ,rlertion and nit, of, and re.ull, ofllained Iron1-an% other f"lrlil,nreul. llrol-Farn, or ,ercir„ o,ell N%Ith the machine, ant] lit ot;ranlnli fill . 'I'll(, Ienn •'nra,hint',•• it, o,cd in flit- \F;reelnrnt rrfrr, Io nlarhinr. anti or Ihrir Tnollel ullcrade, and fr.1111if- unlr Ihr ronte\l rellldire, individual reft•rrnre to nlodrl liprl:lde, and fealure- 1•h, llrire, ,fated herein are exrin,i%e of any rharg;e, 1Slli,'ll art•doe m no% heI-oroe Ilse f ronl the (ll,lmllrr under;ul% 111N1 Ita-r or rental agreement relating; to Iflr machine,. In addition to Ille 11rire„Itrtxcn helo%c, tflr(:u,lonler ag f re,If,ll;n ;unlln lit,rfln;ll to arl% 1;1\e,rr,1111 i1Ig,h mil lilt- \g I c nn•nl.I lr;ul% arli\ilie, her,undrr,e�rlu,ile of Ia�e, hard on eel income. \n.N l,er,onal flrollerlN tape,;t,,e„ahlr on the nuu hint',on of after the Efferti\, Date of Purchase shall he horn, h- the Cu,tollwl. M-L-1' Sri gal I%lit- Ifalnn, Vunlhrr 1.1I,RIu% 14 Ir1Id IInI kill IlII11 3272 002 30090 B Control Unit 889.00 3250, Qty 5 Device nepter 629.00 1066 APL Feature 131.00 1, 649.00 t ^()2- -Q1-902 ---Display -Stati0rr-- -418:00-5 066 -APb-Fentur t. - 1a4:00 — -- —Keyboard-- --- - �9-. 561.00-"�, -327�7 GG2 ----Q1903------- B- Display Station - 1 1, 418.00 4631 ----Keyboa rd I lYl I \I. Th, Mom Ill Ity, art' not I,alid after thr Ilultt;ltion 1.\IIiIn1i11n I);Ilr 'Ilo%,11 ;11111%1, 1 hr"• 1,11, c 111• 11hjr, l If, 4 11,111�I uf�t tII and in- rluding;the Vf(erli%r llalr of Plot ha,e. %%ithio Ihr limit„rI IIII Ili in Ilit,I,ro%i I1III,Ill ;ol% ;t1 llhr;llllr 11M Ir.I I a-I renu1nl eafter, the„llrice,are,nhjerl to%erifiralion and rorrrrinnl h% IIt\1.if nere,,;u\.I'l l"T III,1 ccpt;lo, r. I I11 f fh rli%e D.11r of furl 11,1,e,11,111 he the later of the 1'1feclice Dale of 1)ufllatioll m flit' datr or1 1.hi, It Ihi, \g-rl•( oil nt. -it;llyd I'N th1 I;II,IIIn1rI. i rrl f-ikI'd h1 lli%l ;tt it- Brandt 0111ce adlfre„,horn aho%e. no%idrll Ihat ,ucll rrrriltl i, not I;III•I Illml Ih1•Ouot;llwll (.\11i111i11n Datr. I lit,n1:U hint', %.III he lerminated under tilt,ap1,1it•ali1r Ill\1 lea,,or rrnl;tl ago hrlween 111\1 and the 1:n,lonn•r a,of Ihr da% inunedialck Illrrediog flit, Effertiie Date of Purella,e. 'hill (ar,totner ag;rre, Ihal 11t\1 n1a,t Teolme Iralnrr- or IIn%nt�r.Idc to, Irl,.;11 it- o%%Il r�llrn,e. to fltc alt"1,• nlarhinrc - a111•r Ihr VI- fe1•ti%e Date of 1'nrrh��,e in ordrr Io r11f1t-r I o I•,I hr 1:101Irlr- rlfotol III flit-flit- nun hlnr flr,rrinti"ll, -rl gortll �thf1%r Suh rrnu11a1, or Agreenu'llt for I'll r'eh;l w of In"lidlell 111,11 \luehilles (Col)61111,ltinn Sheet) Cualom-v? Name: City of Wichita Falls �,„,•, ,,•„I 160 1:na u„,•r V,.: 9752900 The,folluwinF m:u•him•s are,snhjerl to tile,rrG•rrnred Al;me•mrnl fin I'un has'.4 I,hl;lll'-d 1IN NI"An". --------1Lu•hine,•--------a __R•;,wrr__I I'm. flan •rinl A vru,lc N1;u him/I c.0mv I'iir No. T% M1lode,l Numhe,r Cat,•ge,n vl Numl''r Ili. iilliin 11 nil I'i I Amount 3277 002 42140 B Display Station 476.00 476 .00 1 1066 APL Feature 154.00 154.00 1 4638 Keyboard 512 .00 512 .00 1 1090 Audible Alarm 69.00 69.00 1, 211.00 3277 002 40145 Display Station 476.00 2 , 856.00 42141 50323 50326 67104 67105 1 4631 Keyboard 77.00 462 .00 1 EB2788 96.00 576.00 649.00 3 , 894.00 ; 3277 002 42139 Display Station 476,00 4, 760.00 50321 50322 50324 50325 67102 67103 67106 77771 79024 1 4631 Keyboard 77.00 770.00 553 .00 5, 530 .00 , 3286 002 80104 Printer 939.00 939.00 1 1066 APL Feature 581.00 581 .00 1, 520.00 , r 3�� • Pave 2 „f 2 �� !3 l.�U fl►I �I..Y: ��3b��6— PA}'''IIF'NT pall, It-conu• Ili• propcM of IB\t WarranIN ,vrkice pro%Idrd under Ihis 1);rrrnic•nl doe, n„I a„ore oninlermlited operation of IIIe muo•bines. 1'acnwnl in lull nnl,t he ,uItmitttd lu Ilt\1 Nilh till, agn•rnn nl, II{\I m:r\, at It, oplion. ,torn, on Ihr cu,hunrr', prenli,e,, maintenance unl-„ till, poroha,r i, al,o Ihr ,ubjert of cut 111\1 IIIIIAlrin•flf P.1\rtlrflf ,yopooIli •urtl or pail. Thal 11M deVol, mere„an to fit 11111 this AgneruenI apprct\ed for lilt, purcha,t-, In N lilt h ra,r, an Ili\1 In" \\.urau\ stallment Pa,mrnl Agrrrmrnl, ,igned b\ Ihr (:u,tonn•r, and the do\,n pit\nu•nt Ibrreuncll-r. i( an\, null Ice ,uIt Ill IIIrd to IIf\1 with till, II tell 1-0'I e1 err till nurrhine•n It-«re-it uvrd /Ie•rennr It,r: Agreement. (:onum nculg oil It"' Date of In�fallalio[] of an additional feature or DATE OF INST.•1LLAPON mould upgrade por,-ha,rll lh-murder and in,talled ,ob,vglo,nt to the Date of In,lallation of Ihr 111.1chinr. HIM Nil] pnr\idr, during the Fur Ihr purpo,t- of thi, Agreenu•nl, Ili- Date. of In,Inll:uion 1, Ibe N•ul,ult, prrod, a tirr\1,t- and I'arl, WWIa[]I%- u, dr,rribed Am%e, for da\ (\londa\ through Frida\) Iollomlig Ihr I1;1\ Ihal dir Ina,hoo. Na, urfl additional f,alur- or nuldrl upgrade in,talled, a, ,pecifird h\ Ifi\i, under the applicable Ill\1 Ira,r ,I rental Doling Ill( \\ananf\ period, engrro•ering chaog", delermine•d ap- agreement betNeen Ili(, parlw,. I'll,able b\ IB\I, well he corillolled an'l in,talled b\ II1\1 tin the Machine. Ibr ('o loolet ml;u, b\ Ill midulg []otter ,ubjt•cl to \siren confirmation 7I7TE It\ HIM. 1-1,41 to h:r\r ool\ o;uilalorn change,, a,dcicrnum•d If% 111\f, it,- ,[all,If ,If nrarflow, Title to each of the machine, ,hall pa„ to Ibt.'(.n'lonu•f a- of Ihr 1•"I- 111\1 ,hall ha\I full and If acre„ to the machine, to pro\ide fect i\e Date of I'urchar ,ubjrrt I„ arrrpt;uu'c' t.l Ill], 1gn rnu I't b\ IB\f 1.1 ire Illrrcom. 'Ihr C11,101iu r hall prompll\ in(nrni 111\1 of amv change in Ibr madmic,' localion during Ihr Narranle penod. RISK OF LOSS OR DAMAGE If the ..arrant\ period r\pirr, on a Frida\ or Sat ifrda\, it will be ex- trmdrll h\ t-ith-r IN,,, d tn, or one da\ re,prctm.k. ,o that the la,[ da\ of I'll lu and including III,. F(frcti\t- Dalr'ot 1'un'ha,e, all I14, of It)" mb "al lam\ period ,.III br ni a timnda\. of or damage• to Ihr marhuu•, „ill Ili- in it.,-of-I'lot v ,fill Ili,- pro\I-u'11- \1 I I'll ItF:�I'1;1 'F 'I'll \l Alt It \\'I•) If \'I'I:(:1)Itl of Ihr ap{di,aWr HIM Ira-t or r-oIA agfc•rnun1 Ibcn I t•tt .,l Ian - ,,I1 )I \( III\I;� \\ 111( II IIl1h: BiA-A 1 l'\I.I.F:I) hlllt 11(Iltf'. rnarluue, lifter Ibr FI1-fi\r I)at c of lilt,ha,c•. all II-k, I.I 1,,— or 1'll \\ it\F: 1 1:11t \\I) \1 1 1i 1t 1\'I l 1'1"I'1:1:(I It It damage ,hall Ill- on Ihr Cu,lomu r 11 \( III\1:S \\ I111 11 11 A\ F: I I F F I\ti'I'\I.1.I. I) I.11it 11(ME PROGRAM MAC I II �\ 'I IIItF F 111)\ III. I"ill•: ( l ST(1111;It 1(:itF:I•:S TO 1'he If"Ili "lnogr;rrnnling•' it, Il,rd iu Ibi, Arrectot•to ,hall mbar I'1 Itl'll %SF: 1'IIF: 1f \l WINS ON \\ \ti IS-' It kris such programming a, lim loan nta4t- rrnrrall\ a\ailalde, Iron) lime to R I F hill F \\ It It \\ 1 1 . rime, wllhoul ,rprralt- chaigi•, for maritiie. of do, I\pr, I'll I cha,ed b\ II. Additional \1,Il earl\ I'fo\i,Ioll the Cu,loner under till, lgrrrnu•[]f. I11\1 ,.ill lurni,h ,ur{1 program sting a, Ilan br n•Ilur,trd h\ Ihr (:u,totncr. Bill furllll-r watraol, 111,11 programming dr,ignalr•d It\ IB\1 for u,r The it-rn •`progl Lill]nling ,ur\Icr," ,hall no.,ol ,Hill ,rr\icr, I, Ili\I %,[III a rn.ithinr and for NLIiIh pnlgtanrfning ,cmic, art• a\ailablr will ma\ grnrrall\ ma{.r ;t\all.tblr e,tlhoul -rpattul t in roltnrrlion conform to Ilt\i , offic1,11 pol,11-11rd ,peoil1cation, Nht•n ,hylprd to Ihr with I)[ogranl till jig. IH\I "Ill drtrrnurtr Ihr plogr.unniing _m''., I.u'tonul If prolw1k o'rd off ,loll nrachinr, Ihrnalirr. HIM gill a\ailablr and thrir durcuiofl p1mldc prorrunnlinr ,t I%Itc,. ,uh)rol to the pro%I,rIOI, .laird tit Ihr .. . �u• Icon, progranlnune; and "proglanntiing ,rr\irr,"' .11, not n1- S,-rhon rnlitlyd 1'ro>;r;nnnling elude 111\1 1.1 or[,un, and -wr\1.v- 111.11 .11,- ,1\a11ablr• for a 'I I'm nlc• IIAI II It-, not \,.Ilr;nil trial ihr Iltnrlion, contained in Ihr program- charge tut- \,hirh are o11-reel nndrr ,ri.Ir.itc \,1111,II Irfrrrtuill,. film, „III op"Iah. it] Ihr ronII)III I-if, Nllirb roa\ br ,circled for u,,- by Ihr (:u-Ilnoor. or \,ill no•rl Ihr I.If,loni•r•, Iv,lit ir-no•nl- CONFIG( RAPOA (:!! 1AGF..S• III IT I'Itul:lt 111111NG Fill \\ IfI('If NO 11Itl)I:K \.1111ING AdiinntaI IVallIIII" slut ImitIrI ,oll%VI.ion, Nhit if all. lu IIl in,t•dl;thlr tiFIt\ II F;; It I, \\ \I .UtI V IS IUIS•I HIM IT,I (1\ %N "Ati tna\ hr ordered in \,riling b\ Ihr I'"'lo1111 r undr-f Il rr,-n i, lgu'111, 11 1S•' It\CIS \\ I I III II I A Mutt 1\'I It :tile flow afire it, 'I."rptanor b\ 11I\t, for in,t.11lalioo in Ihr In;tolllnr, ,ubjeol to IBM" prier, till-[] gt-nrr•tll\ In rlit•rl. I11\1 doe, nol ualranl that the operation of the machine or program- thing \,ill bt- tiloolrrlupled nr error fret-, or that all programming WARRANIIES error, \,III Ito rorrrrlcll. III I:\I lu,ion, The Nlllo\,ing \larranlie, 111all appl\ to tilt- maritime, dr,rriicc•d Tbr \\cur.ultir, pnnidcJ b\ IIM under tilt, ,\grccownt do not in- herein: rindr: I. A rrp.111 of 'holage or morel,(, in ,rr\ior till]'. cau,rd b\ fallure u,tirnicr ;unll'arl, \lararlt\ co[]finu;dl\ Ili—Idr a uilaItlr in'tallation emitonlnenl wish all The Narramf\ period i, out- \r;u flu" tilarranl\ I:atrgor\ \ ntachlnr, facihlir, pn•,crbrd h\ dir appInaldc Ili\f ul,talLltlon manual In- ft•aU1r'r,, anou t • and r n ho r nollh, for \l arralll\ rlulb I'll[ "Ill Iltnilt•tl to, lilt- f;ulore Io pro\idc, or flit- failure elf, d ulel u I rradr, Calegorn II mlal hinc••. feature" and Imod-I upl;radc,. Thr %,imafll\ adrlfuatt- rlrririr,tl po\,rr, an" conditioning or homlidli\ control: period connorrtcc•, on tilt. Daly (it I11,1allat1,11, of ihr machine, I-alurc: b) Icp.tir of thlo-ge or inrrca,- in ,cr% e time c;ol,rd b\ file use of or model upgrade the machine, tot olhrr Ihan data prone„iog put11—c, for Nhirh dr,irnc d, I,f"ids re.xpeet 11)InferIfine.x if hirh hnre•horn irlrrollco'.n.r of FIIe 1',f- ,1 n I air of damage• replacroenl of part, (due to other Ihan normal feelirrl)frlrofl'urrhnxe.forle.,,llurnthe Icnrrfurh Irevio,l,ln•ri/ifvl Near) of rrprlllnr ,vt\ice call, calked In tilt, if,(. of ,mpplie,; 1) "T,111 of d.uli,Irr r e o Inrra,r if)1 ,cr%I(v lou caud b\,r : accident; for xurh mnrllilre•r Ji,a,Irr, %,ho It ,hall includr, It'll till[ he limited to, lire, flood, water, Nioll and lightning: Iran,portalion: n-glert or n1i,u,e; alterations, Contnuncillg on Ihr 1:(tirti\r Date of I'urrha,r anLl ronlinniog ""it -1f.111 include, Itut not hr Iinlilt-d to, an\ dc%ialiom from IB\f•s lhrtolgh Ili,- remaiudrr of Ihr Narr;ull\ p-rod, IIN :[];rrr, to pro\idr. .it ph\,i, 11. nu•chanu'al or err,bleat machine dr,Irn; allachnu'nt,. Nhich no additiollal chalre to tilt, I:u.lonnrr, r\rrpl a, ,ci lorlll of lilt. tirotoln are dcfuo•d a, ihr Inr, al, rlrclric:tl or elcrlronlr ortrro otmecitorl '.Milled ••F`Nrltl,inn,.•• Naua[]l\ ,(-r\icr to krep ihr ma,hint., in. or It, an Ilt\I marlont. of non HIM rlluipnu'nl and dr\irr, tin[ supplied b\ re,torr lilt, machine, Ill. good No1l,utg order hill, \,;unlit\ .cr\irr in IH\I; iu IBM fill, burr,, tllo,r IIN lomhin-, \,hick are uNnt-J bit elude, ,ehednit-d pre n\- ri\r nu l. nlcomnv bard upon Iht- ,prl111c I11\1, bider Ihr tirr\ity and Pall, llarralm pro\i'loll of an IIN put-- nerd, of uo mdua) Inarhulc, a- dr-frl ntlnrd b\ HIM ;lld un,rItrdulc•d. ha". •tgrrrmu•nl or folder all 111\1 Mal ntt-naume ageecoi•nl; on-calf renn•dial nlainlrn.Inr,• �uI IfInalntc•n;n( \,ill imrindr lubrication. ad)u,[men I,, and replacement of parf, drrmo•d n,-(r,,;tf\ '•) It-j"m of d.unar;t• of Ill.wa,c of ,vIN11v tine• I;Io,rd I,\ the con- b\ 111\1 l'arl, \,111 be Iurti-hrd on am r\rhan a ge ha i,, nd the rwph, -tl rf Ion Ifofn one HIM model to :mmtlher of tilt- In,tallallon or rt-no,\al of . ;I11 lit\i f,-;ll lit l' Nhrllt-lt'I .III\ of Ihr folt-go''19 Nor- pri torincd b\ other 2 than IU\I Ifli, rxrin,iorl .hall alllli, onlN Ilm11lig the three nnmJh, oh l,atrnt. III\1 Hill lla, n"nitnll roll,, ,i:una}e, an,1 anonu,', Ire. cr,lllrnl to Ihr (fair of ,uch machine nnnlifi,al ion: 1) alhfitiomal ,rr,il,• liner anll rrl,latetnrnt I'm 1, a,,,r flnalk aaal,lr,1 lvmcil{,',l Ihal: rcllr,i .,tth Ih,• in,lallalion Ill, II3\1 Irf an enginrrring rhanRr ,.hen ,ml h a,11111ion;ll a) Ihr I'm.l,nnr r llr''Illptl. notllic_ HIM in „rilnlr If Ihr ,Lu111: and st•rnn'I• .1 fill It;][1, at I- rr,Ioircd tier In Ih(1 con.rl-i,nl front mw IlM h) III\I h,t• ,ore rmill d (If Ihr ,h•fen,I• alid :111 relatr,i ,elllrvn,•ni mI del II, another tit Ihr in_lall:llil II or r,'rn,,,:11 of all IIII featIIrr nrrr,l r,In,n, whrne,rr an, of the Iorrenine aa, lu•rfornlyd h, ,Irhrr Ih:ul Iltv1, g) fifmi,hing ,u .II _ err al.,I,.- II ,mrh , InuII II III rurII I ,Ir nl Ilt\I', mint i_ hkrl, III urrur. Ihr I'I Ilru•,, lt;nntul� I,r lrlinl,llin� file "l machine, or fornl,IsiIIR nlalrrial Ihrrefor. in-pc.ling nla,him,•-, altr„', 1.u,I,Inu'r tWlC,•. III ll,'r nlit III\I, .It II, ,y1litln anll r�I,en,r• richer In I making ,l,rrifiralmll r I,r,Irllre f,tr lhl, I:u,tlnnrr Ihr nvhl It t,IotIooe 11,mlr Ihr Ina,"Ill nr, or hanl;r, or Iu•r(ornunk ,rr,ur, r,Innrrl,'d „iIh r rl ora l l l tll of Ill a I. I I_. or adding fir remotiII a It al. 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I'I{111'(Iti\I_N ()it Pit llllt \(:1={1"1•;- brnrlght h\ rithrr parr nnlrl- Ih;ul Iwo \ear, aflrr ihr rang ,( a,lion Ila, ari,rn, or, in the ran of non pa\nv`nt. rnnrr Ulan t\.o \rarer from 111A I SS ()It %1, Illt \1 it I`I I.\, \\11 \I.1. I)I I I I I I t If Il- Ihr date of till- la'l pa\,nt-nt. 111 \I1:\ I IONS BE'I \1 1:1:\ l llI: \•I I\(: TO Ihi, ,19rvemvnI will lit- gmernl-d b\ Ihr law, of flit- Stall- of 1'L\. I IIF SI 11,11:( "I' 11 \I"I I;It O 1'lll� kGRI":1;111."N' T. l ork. N i I i i i i ,I F H-vi\l-d h\ 111\1 ;It_W�st__Cen _za1 _Texa 160_______ ------------------------------------------------------------- I;\ I ()II ____________________________________________________________ I L,, International Business Machines Corporation ------------ --City Of Wichita Falls It\------------------------------------------------ --- It\ ------------------- - ------ — — _ _ _ _ . ---------------------------- ---------—---- I)II--- ---------------------- _ tell- PRESS FIRMLY WITH BALL PAINT PEN ON A HARD SURFACE FOR MAXIMUM LEGIBILITY. International Business Machines Corporation Armonk, New York 10504 113M Matntenanee Agreement IBM Branch Office Address: Agreement No.: IBM General Systems Division One Summit Avenue Marketing Branch Officc No.: G6A/BCV Fort Worth, Texas 76102 Name and Address of Customer: Customer No.: 9 7 rJ 0 2—4 2 City of Wichita Falls Data Processing 1300 Seventh Street Wichita Falls , Texas 76301 International Business Machines Corporation (IBM), by its acceptance of this Agreement, agrees to provide and the Customer agrees to accept, under the terms and conditions of this Agreement, maintenance service for the IBNI rnachincs, including IBNI features, shown on the attached IBM Maintenance Agreement Machine list and for those IBM machines and feature= for which such service is ordered from time to time by the Customer,subject to written acceptance by nlNI Term or Sundays. The Customer may change the selected Periods of Main- This Agreement is effective from the date on which it is accepted by tenancc Service Availability upon 15 days'prior written notice to IBM IBM and shall remain in force until terminated by the Customer upon In a single systern, all machines covered under this Agreement must one month's prior written notice to IBM or by IIIM upon twelve rnontlrs' have a common period, Monday through Friday, of at least 9 con- prior written notice to the Customer. Individual machines may he with- secutive hours within the selected Periods of Maintenance Service drawn from this Agreement by the Customer upon one month', prior Availability. For this purpose, a single system is defined as a coin- written notice to IBM Except as otherwise provided herein, IBN1 otuv bination of machines, including one or more controllers or processing withdraw individual machines frorn this Agreement at the end of the units,which are designed to operate in conjunction with each other and first year after maintenance service for each such machine ha, cony- arc interconnected by IBM power and signal cables or the equivalent. rnenced, or thereafter, upon three months' prior written notice to the For Monthly Use Plan machines, the Customer is entitled to Main- Customer. tenance Service Availability 21 hours a day,7 days it week. Maintenance Serrice Charges The Maintenance Service Commencement Date for a machine under Maintenance charges for a machine will begin on the Maintenance this Agreement will be the date designated by the CuslViner nr the day Service Commencement Date. following the last day of the Service and Parts Warranty period of Ilw For rnachincs, other than thosedesignated b) IBM as !Monthly Use applicable IBM purchase agreement, whichever is later. IBNI agrccs to Plan machines, the Customer agrees to pay monthly charges consisting provide the availability of maintenance service during Periods of Hain- of(1)a Minionnm Monthly Maintenance Charge, and(2)an Additional tenance Service Availability selected by the Custorner, or during thc. Monthly Maintenance Charge for any Optional Periods riods of Maintenance period specified for machines designated by IBNI as Monthly Ilse Ilan Service Availability selected by the Custorner as described in the at- machines, while they are located within the United Stales and Puerto lachrd IBM Maintenance Agreement Exhibit. Rico. This maintenance service to keep the machines in,or restore the For Monthly Use Plan rnachincs, the Customer agrees to pay month- machines to, good working order includes scheduled preventive main- IN, charges consisting of(1) a Basic Monthly Maintenance Charge, and tenance based upon the specific needs of individual machines as deter- (_�)an Additional Nlond ly Maintenance Charge hased upon the arnount mined by IBM and unscheduled, on-call remedial maintenance. Main- of processing performed by the machine as measured by an IBS, meter tenance will include lubrication,adjustments and replacement of main- multiplied by the Additional Monthly' Maintenance Chargc Rate. In or- tenance parts deemed necessary by IBM.Maintenance parts will be fur- der to ensure timely meter readings, the Cuslonm•r agrees to furnish a nished on an exchange basis, and the replaced parts become the monthly report to IBM showing the meter reading for the machine as of property of IBM. Maintenance service provided under this Agreement the close of the last work day of each calendar month. The Custorner does not assure uninterrupted operation of the machines. agrees to use due care not to interfere with the proper operation of the meter. Periods of MBlntenancc Service Availabil ty If the Customer requests maintenance service, that is not otherwise excluded as set forth in the section entitled -Exclusions,- to be per- For machines, other than those designated by IBM as Monthly Use formed at a time outside the selected Periods of Maintenance Service Plan machines, the Customer may select a Minimum Period of Main- Availabilitv, there will be no additional charge for maintenance parts; Icnance Service Availability during any period of 9 consecutive hours however, the service will be furnished at IIIM's applicable hourly rates between 7:00 a.m. and 0:00 p.m., Monday through Friday. The and terms then in effect. Customer may select in lieu of, or in addition to, the Minimum Period There will be no additional charge for travel expense associated with of Maintenance Service Availability one or more of the Optional services performed during the selected Periods of Maintenance Service Periods of Maintenance Service Availability as shown on the attached Availability,except that actual travel expense shall he charged in those IBM Maintenance Agreement Exhibit.The Period or Periods of Main- instances where the site at which the machine is located is not normally tenance Service Availability selected by the Customer most include it accessible by private automobile or scheduled public transportation. period,Monday through Friday,of at least 9 consecutive hours. Changes in the machines' specifications may result in an adjustment The Period of Maintenance Service Availability for a machine on of the Minimum Monthly Maintenance Charge and Additional Monthly Monday through Friday shall be the sarne hours each dav, and the Maintenance Charge or, for Monthly Use Plan machines, an ad- period on Saturday or Sunday shall be the same hours on all Saturdays justnrent of the Basic Monthly Maintenance Charge and Additional / Please send all communications ,imi at its business of fire listed shore unless notified to the c•ontrarr. Z120-07776 it) ICTr"xn^Ff? Monthly Maintenance Charge Rate. Surh adjustnn•nt(s) shall bp of hl n, it er ice which i, impracticel 1,,r Iltxt Ire render hecau,e of fective on the Maintenance Service Commencement Date shown on the alterations in,or attachments lo, the machines. IBM Maintenance Agreement Machine List. The Minimum Monthly Maintenance Charge, Periods of Main- 4ccos.s to ,llachin•s tenance Service Availability, Machine Groups, percentages by which the Additional Monthly Maintenance Charge is detcrininrd, Basic IB%I shall have full and free access to the nun hires to pn»ide ser- Monthly Maintenance Charge and the Additional Monthly Main- Ocr thereon. tenance Charge Rate are subject to change by IByi upon three months' If persons other than IBM representatives shall perlorm maintenance prior written notice to the Customer and will become effective on Ihr, or repair of a machine,and as a result further repair by IBM is required, date specified in the notice unless the Customer exercises the option to such further repairs will he made al IBM's applirahle time and material withdraw the affected machine from this Agreement. rates and terms then in rffvct. It such additional repair is required,IBM may withdraw the marhine from this Agreement upon one month's Taxes prior written notice to the Customer following any repetition of the need for additional repair of such machine caused by non-I13y1 main- In addition to the charges clue under this Agreement, the Customer tenance activity. agrees to pay amounts equal to any taxes resulting from this Agreement, or any activities hereunder, exclusiv; of taxes based upon Engineering Changes — Installation and Control net income. Engineering changes, determined applicable by IIIM, will he con- Invoicing trolled and installed by IBM on machines covered by this Agreement. 'hhr Customer rnay,by providing notice subject to written confirmation The Minimum Monthly Maintenance Charge, Basic Monthly Main- by IBM,elect to have only mandatory changes,as determined by IBM,in- tenance Charge and the Additional Monthly Maintenance Charge for stallyd on machines so designated. machines other than those designated by IBM as Monthly Use Plan IBM reserves the right to charge,at its applicable time and material machines will be invoiced in advance as of the first of each month. rates and terms then in effect, for additional service time and Charges for a partial month's service will be prorated on the basis of a replacement parts associated with the installation by IBM of an 30-day month. The Additional Monthly Maintenance Charge for engineering change when such additional sericr and parts are Monthly Use Plan machines will be invoiced in the month following the required due to the conversion from one IBM model to another or the in- month in which it is incurred. Payment will be made within 30 da n ys af- stallation or removal of a IBM feature whenever any of the foregoing ter the date of invoice.All other charges due hereunder are payable as was performed by other than IBM. specified in the invoice. Non-IBAI Parts Exclusions Maintenance service provided by IBM under this Agreement does not include the replacement or adjustment of parts which were not fur- Maintenance service provided by IBM under this Agreement does not nished for the tnachinr by IBM, or the time spent in determining the include: need for replacement or adjustment of such parts, except for common hardware items such as screws, nuts, bolts, clamps and cnmmercially- (a) repair of damage or increase in service time caused by failure to available parts; e.g., light bulbs, etc. IBM will replace, at the continually provide a suitable installation environment with all Customer's request and at IBM's applicable time lilt]material rates and facilities prescribed by the applicable IBM installation manual in- terms then in rffect, maintenance parts which were not furnished for eluding, but not limited to, the failure to provide, or the failure of, the machine by IBM (ex(ept when such part is in an allrration) when adequate electrical power,air conditioning or humidity control; such harts are directly interchangeable with the I13NI maintenance parts. (b) repair of damage or increase in service time caused by the use When IB.x1 determines that a machine under this Agreement contains of the machines for other than data processing purposes for which a part, not furnished for the machine by IBM. which is particularly designed; significant to IBM's ability to provide maintenance service for such machine under this Agreement, IBM may withdraw the machine from (c) repair of damage, replacement of parts((file to ether than nor- this Agreement upon one month's prior written notice to the Customer, mal wear)or repetitive service calls caused by the use of supplies; unless the Customer replaces the part with a directly interchangeable (d) repair of damage or increase in service time caused by: acci- part furnished for the machine by IBM. IBM will, at the Customer's dent:disaster, which shall include, but not be limiter) to, fire, flood, request, replace such part with a directly interchangeable part at IBM's water, wind and lightning; transportation; neglect or misuse; applicable time and material rates and terms then in effect. alterations, which shall include, but not be limited to, any deviation from IBM's physical, mechanical or electrical machine design; at- Ui,sclainter and l,intitation of Liability tachments,which are defined as the mechanical,electrical or electronic IIIM will in no event be liable for lost profits or other consequential interconnection to an IBM machine of non-IBM equipment and devices damages even if IBM has been advised of the possibility of such not supplied by IBM;or IBM machines,except those IBM machines which damages or for an claim against the Customer b any other .)arty. are owned by IBM, under the Service and Parts Warranty provision of g y g` y ` I` IBM's liability to the Customer for damages, from am' cause what. an IBM purchase agreement or under an IBM Maintenance Agreement; soever, and regardless of the form of action, whether in contract or in (e) repair of damage or increase in service time caused by the roil tort including negligence, shall be limited to the greater of$50,000 or version from one IBM model to another or the installation or rrmoval of twelve months' maintenance charges for the specific machines under an IBM feature whenever any of the foregoing was performed by other this Agreement that raused the damages or that are the subject matter than IBM.This exclusion shall apply only during the first three months of or are directly related to the cause of action. Such charges shall be of IBM Maintenance Agreement service subsequent to the date of such those in effect for the specific machines when the cause of action arose. machine modification; (0 replacement parts or increase in service time as set forth in the General sections entitled "Access to Machines" and "Engineering Changes — Subject to the terms of the following paragraph, IBM may, upon Installation and Control" or replacement of non-IBM parts as set forth twelve months' prior written notice to the Customer, modify the terms in the section entitled"Non-IBM Parts"; and cnnditions of this Agreement, except that IBM may, upon three furnishing supplies or accessories, painting or refinishing the months' prior written notice to the Customer, modify the terms and (c g PP p` g conditions of the Section entitled "Charges." machines or furnishing material therefor,inspecting altered marhnn•s, Any such modification will apply on the effective date specified in making specification changes or performing services connected with the notice unless the Cusromer exercises the option to terminate this relocation of machines, or adding or removing accessories, at- 1 tachments or other devices; Agreement. Otherwise, this Agreement can oniti be modified by a writ- ten agreement duly signed by persons authorized to sign agreements (h) electrical work c)mernal to the machines or maintenance of ac- on behalf of the Customer and of IB.M,and variance from the terms and cessories, alterations, attachments or other devices not furnished by conditions of this Agreement in any customer order or other written IBM;and notification will be of no effect. 2 I hf ft'I;rest-11t` , „o `WTI,T of I", "1 i ."• 11;,sir i ; , i I .. this Agreement,or,if not the owner,has authority front the owner to in- l ork. clydc sub hlnachines under this Agreement. THE, (:I IS'I'011Ell ACKN(IXX LEDGES 'I'HA'1' HE HAS 113M service provided outside•the seopc of this Agreement will be fur- R E W '1.1115 AGIi 1•:I•:MEN'1•, WH ICIf INCLUDES '1'l11•; A'I'- nisited at IIIM's applicable time and material rates and Iernts Ihcn in ef- TM 11El) 11111 MAINTENANCE AGREEMENT NIACHINE, (feet, unless such service is otherwise covered by a separate II1M I.IS'1' AND IF3,11 N:XIN"I'l"NANCE AGRh:l•MEN'I' EXIIIIIIT, agreement. UNDERS'T:1NDS I'll', AND AGRF,h:S 'TO BE BOUND BY ITS IBN1 is not responsible for failure to render service due to causes 'ITAI11S AND CONDITIONS. FURTHER, THE CIiS1,0:11ER beyond its control. AGRLES 'I ILAI' I'1' IS 'I'FFE CO111,11:1'1%, AND EXCLUSIVE Either party may terminate this Agreement for failure of the other to S•T'X"I F:IENT OF '1'IIL :XGRNF.11h:NN'l' Bh:'1'XVFEN TIIF. comply with any of its terms and conditions. PAli 1'1ES, 1X'lllCII Sl'l'EItSEDI•:S ALL PROPOSALS OR No action,regardless of form,arising out of this Agreement may be 1'IIIOH AGHb;h:MEN'1'S, ORAL OIt 1X It I'll"FLN, AND Ala, brought by either party more than two years after the cause of action O'I•llElt C(►1111UNIC TI(P S 13I•;"1'1NELN 'I'llE VAItI]ES has arisen,or,in the case of nonpayment,more than two years from the ItLLA•I'ING '1'(1 'I•HE SI'11JK(:"I' 11:1"1"Thai OF TIIIS date of the last payment. AG ItEF: Nll1':N'I'. r Received by IBM at---------------- --------------------- Branch Z)--ce Name/Number By-------------------------------------------------------. Manager's Signature --------------------------------------------------------- Manager's Name (Type or Print) On------------------------------------------------------- Date Accepted by: International Business Machines Corporation ----City-_of-Wichi-ta--Falls-------------------- custumer By------------------------------------------------------ 13y------------------ ------------ ------------------------ Aulhmi7i4l Sit nature Aulhnri�ed Sienulu v •------—----- --- — --- ----------------------- -------- ....------- -- ---------------------- Nair- CI vpeor Print) Name IT>'eeot 1'i-11 ---------------------------------------------------------- —---------------------...------ ------------ -- ----- Tille '1'itic Oil----------------------- -_---—-—---------- ------------ Oil---------------------------------- ------------------------ Date hale PRESS FIRMLY WITH BALL POINT PEN ON A HARD SURFACE FOR MAXIMUM LEGIBILITY. Z120.07776 (U/M 025)REV.10/76 3 GROUP HOSPITAL SERVICE, INC. (Herein called the Carrier) Dallas,Texas has issued this I! `t l Non-Cancellable EXPERIENCE RATED GROUP COMPREHENSIVE BLUE CROSS AND BLUE SHIELD CONTRACT to the Employer named in the application herefor and thereby the Carrier agrees to provide the benefits detailed herein, all in accordance with the conditions and provisions hereof, including those set out on the following pages which are a part of this contract as fully as if recited ovei*e signatures hereto affixed. This contract is issued in consideration of the application herefor made by the Employer and of the timely payment of premiums as provided for herein. It will become effective on the Contract Date stipulated in such application and will be continued in force, subject to the Employer's right of termination, for so long as the minimum employee participation is main- tained, as set out in Article VII,Section A,Subsection 3. i IN WITNESS WHEREOF, the Carrier has caused this contract to be executed at its Home ( Office in Dallas,Texas. President (% Secretary �• Countersigned: Registrar L - �— Form No. CBCBS-2 STOCK NO. 2200.000-AL580 ARTICLE I - DEFINITIONS i AS USED HEREIN: A. EMPLOYER means, in addition to the person, firm, or institution named in the application herefor, one or more subsidiaries or affiliates listed as such under Eligibility Regulations in the Schedule. 1 B. EMPLOYEE means a person who regularly renders personal services, not less than one hundred twenty (120) hours per month in the business of the Employer, and who (except in the case of a proprietor, partner, or corporation officer or director) is compensated for such services by salary or wages. C. DEPENDENT means: 1. An employee's spouse or 2. Any unmarried child who is either under twenty-five (25) years of age or disabled; provided that in the case of a disabled child twenty-five (25) years of age or older, such child is depen- dent upon the employee for more than one-half of his support as defined by the Internal Revenue Code of the United States. "Disabled" means any medically determinable physical or mental condition which prevents the child from engaging in self-sustaining employment; provided that the disability commences prior to such child's attainment of age twenty-five (25) and that satisfactory proof of such disability and dependency is submitted by the employee within thirty-one (31) days following such child's f( attainment of age twenty-five (25). "Child" means the natural child of the employee; a legally adopted child (including a child living l with the adopting parents during the period of probation); a stepchild residing in the employee's household; or a child permanently residing in the household of which the employee is the head and to whom the employee is legal guardian or related to the child by blood or marriage. As a condition to the continued coverage of a child as a disabled dependent beyond the age of twenty-five (25), the Carrier shall have the right to require periodic certification of the child's physical or mental condition but not more frequently than annually after the two-year period following the child's attainment of age twenty-five(25). D. PARTICIPANT means an employee or a dependent, as above defined, whose coverage hereunder has become effective in accordance with Article II. E. MEMBER HOSPITAL means any hospital located in the State of Texas with which Blue Cross of Texas has entered into a written Member Hospital Contract for the rendition of care for which benefits are provided by Article V of this contract, or any hospital located outside the State of Texas with which any other Blue Cross Plan has entered into such a contract. F. NONMEMBER HOSPITAL means any hospital other than a member hospital which is registered. with the American Hospital Association and approved by the Carrier for the rendition of services on a nonmember hospital basis. G. THERAPEUTIC CENTER means an institution other than a member or nonmember hospital which is approved as a therapeutic center by the Carrier. H. PHYSICIAN means a person (other than a hospital resident or intern) who is a Doctor of Medicine, Doctor of Osteopathy, Doctor of Podiatry, Doctor of Dentistry, Doctor of Optometry, or Doctor of Chiropractic, or a psychologist who is certified and licensed by the Texas State Board of Examiners of Psychologists under Article 4512c of Vernon's Civil Statutes of the State of Texas, a STOCK NO. 2201.000-AL479 ARTICLE I — DEFINITIONS (Continued) I R. BED-PATIENT HOSPITAL EXPENSE means charges incurred for the items of service or supply listed below for the care of a participant; provided that for nonmember hospitals such charges are reasonable; and provided further that such items are: (a) furnished at the direction or pre- scription of a physician; (b) provided by a member hospital or a nonmember hospital; and (c) furnished to and used by the participant during a hospital admission. Bed-Patient Hospital 1 Expense incurred by the mother for delivery of a child shall be deemed to include routine well- baby nursery care of the newborn child during the mother's hospital admission for the delivery. An expense shall be deemed to have been incurred on the date of rendition of the service for which the charge is made. 1. Room accommodation charges, provided that if the patient is confined in a private room the excess of the room accommodation charge over the hospital's average semiprivate room accommodation charge will not be considered hereunder for any purpose. 2. All other care in the nature of usual hospital services which are necessary and consistent with the condition of the patient. S. OUTPATIENT HOSPITAL EXPENSE means charges incurred for items of service or supply for the care of a participant, provided that such items are: (a) furnished at the direction or pre- scription of a physician; (b) provided by a member hospital, a nonmember hospital or a thera- peutic center; and (c) furnished to and used by the participant during an outpatient visit; and provided further that for nonmember hospitals and therapeutic centers, such charges are reason- able. An expense shall be deemed to have been incurred on the date of rendition of the service for which the charge is made. } T. OTHER MEDICAL EXPENSE means charges incurred for the items of service or supply listed J{ below for the care of a participant, provided such charges are reasonable and such items are: (a) furnished by or at the direction or prescription of a physician and (b) are not included as an item of Bed-Patient Hospital Expense or Outpatient Hospital Expense undQr Section R or S of this Article I. An expense shall be deemed to have been incurred on the date of rendition of the service for which the charge is made. r 1. Services of physicians. 1 2. Services of a certified registered nurse-anesthetist. 3. Services of a private-duty registered nurse or licensed vocational nurse not related to the patient by blood or marriage. 4. Services of a licensed professional physical therapist. 5. Diagnostic x-ray and laboratory procedures. 6. Radiation therapy. 7. Drugs and medicines purchased for use outside a hospital which require a written prescrip- tion for purchase, but only if "Applied For" is indicated in item 7 of the Schedule. 8. Rental of durable medical equipment required for therapeutic use unless purchase of such equipment is required by the Carrier. The term "durable medical equipment" shall not include equipment primarily designed for alleviation of pain or provision of patient comfort. 9. Professional ground ambulance service used to and from the nearest hospital appropriately equipped and staffed for treatment of the participant's condition when rendered in connec- tion with outpatient care following accidental injury occurring immediately prior to the 1 hospital visit or in connection with bed-patient care. _ o n STOCK NO. 2202.000-AL479 j ARTICLE II - ELIGIBILITY FOR COVERAGE; EFFECTIVE DATES 1 A. ELIGIBILITY FOR COVERAGE 1 1. Any employee of the classifications described under Eligibility Regulations in the Schedule shall, upon the later of completion of the length of service therein specified or the contract date, become eligible to apply for coverage hereunder for himself or for himself and his 1 family members as dependents. 2. Family members acquired after the effective date of the employee's coverage shall become 1 eligible on the date the family member becomes a dependent as defined in Article I, Section C, of this contract. 3. Coverage of the employee, shall be a condition precedent to coverage of his eligible 1 dependents. B. APPLICATION FOR COVERAGE 1 Coverage of each eligible employee or dependent shall be contingent upon the employee's 4 making application therefor in accordance with the approved procedures established by the Carrier; thereupon,subject to acceptance by the Carrier, coverage shall become effective in accordance with the following sections of this Article II. C. EFFECTIVE DATES—EMPLOYEES If the application is for coverage of an employee or of an employee and his eligible dependents, and 1. If the employee is eligible on the contract date and if the application is made prior thereto, the coverage shall become effective on the contract date. 2. If the employee becomes eligible on or after the contract date and if the application is made after the contract date but within the first thirty (30) days following the date of eligibility, and a. If "Standard Option" is specified under Effective Dates in the Schedule, the coverage shall become effective on the employee's date of eligibility; b. If "Option I" is specified under Effective Dates in the Schedule, the coverage shall become effective on the second premium due date following the date that the application is made; c. If "Option II" is specified under Effective Dates in the Schedule, the coverage shall become effective on the first premium due date following the date that the application is made. 3. If the application is made more than thirty (30) days after the date such employee becomes eligible, the coverage shall become effective on the later of the succeeding contract anni- versary or the first premium due date occurring thirty (30) days after the application is made, f provided that if the employee elects, or is required by the provisions of Section B of this J Article II to submit evidence of insurability satisfactory to the Carrier with his application, the coverage shall become effective on the first premium due date following the date the Carrier determines such evidence to be satisfactory. 4. Regardless of the above subsections of this Section C, if "Other" is specified under Effective Dates in the Schedule, coverage shall become effective as set forth thereunder. D. EFFECTIVE DATES— DEPENDENTS If the application is for coverage of a dependent of an employee already having coverage under this contract, and STOCK NO. 2203.000-AL479 rn Ml 99M ARTICLE III - PREMIUMS A. The premium rates initially effective shall be shown under "Premiums" in the Employer's Applica- tion, and continuance of the coverage hereunder shall be contingent upon payment of the premiums by the Employer at the Home Office of the Carrier in Dallas, Texas, in accordance with 1 the following provisions: the first premium is due on the contract date; subsequent premiums are, during the continuance of this contract, payable in advance. The Carrier may refuse to accept any payment which does not represent a total monthly premium. 1 B. This contract shall be nonassessable. It does not share in the earnings of the Carrier, but the Carrier reserves the right to change the premium rates on any contract anniversary, as applicable to the succeeding year, commencing with the contract anniversary stipulated in the Application, 1 provided that: 1. If the Carrier does not change the premium rates on any of the above contract anniversaries, 1 it shall have the right to change premium rates once on any premium due date occurring between such contract anniversary and the next succeeding contract anniversary and such change shall be applicable to the contract months succeeding such premium due date; 2. In the event price controls are established by the state or federal governments while this contract is in effect, the Carrier reserves the right to adjust premium rates on any premium due date occurring between the date of imposition of such controls and the contract anni- versary following termination of such controls. J Any such change shall be made uniformly applicable to all employees within any sub-group or other classification under this contract. C. Premiums may be paid on a monthly, quarterly, semiannual, or annual basis as the Employer lmay elect, but without discount. 1 D. The premium to be paid hereunder shall be determined by multiplying the number of employees covered for each classification by the rate then applicable for that classification, and totalling 1 the extensions thus obtained; provided, however, that for participants whose coverage becomes effective in accordance with Article II on other than the first day of a contract month,no premium shall be due for any portion of the contract month in which the coverage becomes effective. E. A grace period of thirty-one (31) days, without interest charge, shall be allowed for the payment of each premium except the first. If any premium is not paid within the grace period, this contract shall terminate at the end of such grace period, except that the contract shall terminate at an earlier date (which is not prior to the end of the period for which premiums have been paid) provided the Employer shall have given the Carrier written notice of such earlier date of termina- tion in accordance with the provisions of Article VII,Section A. If the contract terminates during or at the end of the grace period, the Employer shall be liable to the Carrier for payment of a pro rata premium for the time the contract was in force during the grace period. The allowance of the grace period is applicable only to the total premium, and shall not be construed so as to extend the coverage of any employee for whom a premium has not been paid as a part of the group remittance. IN EW (V ---- ARTICLE IV- PAYMENT OF BENEFITS; COORDINATION OF BENEFITS A. Payment of benefits by the Carrier to the supplier supplying the care or to the employee, as the Carrier may elect, shall constitute full discharge of all responsibility of the Carrier to the employee on account of care rendered to any participant under this contract. B. It is understood and agreed that the allowances set out in Article V for services and supplies rendered by a supplier other than a member or nonmember hospital or therapeutic center are not intended to and do not fix the value of the services of the supplier nor in any way relate to or regulate such value; that the supplier is privileged to make its regular charges and that the stipulated amounts are merely to apply as credits thereon. C. Any benefits hereunder, payable to the employee, shall, if unpaid at his death, be paid to the surviving spouse of the employee, as beneficiary; if there is no surviving spouse, then such bene- fits shall be paid to the employee's estate. D. The benefits provided hereunder are not assignable. E. It is hereby declared to be the intent of the Employer and the Carrier that the availability of the benefits herein specified shall be contingent upon the absence of other coverage. Any other contract or policy or employee welfare benefit plan under which the participant holds protec- tion for hospitalization and/or medical-surgical expenses by virtue of his membership in or relation to a particular group shall be considered "other coverage" within the meaning hereof, whether the benefits are in the nature of indemnity or prepaid services. The term shall likewise be deemed to include any governmental program existing by statutory authority under which he is entitled to hospitalization and/or medical-surgical benefits. The term shall not be deemed to include any coverage held by the participant for hospitalization and/or medical-surgical expenses which is written as a part of or in conjunction with any automobile casualty insurance policy. When, therefore, other coverage applies, the benefits of this contract shall be coordi- nated therewith and determined in accordance with the following subsections of this Section E: E- 1. The benefits of this contract shall be modified by the provisions of this Section E only when the Carrier is the "Secondary Carrier." The Carrier is the "Secondary Carrier" when the other coverage has provisions which state that it will provide its full benefits regardless of the bene- fits of this contract or when the other coverage has provisions corresponding to the provisions of this Section E and: a. The patient is classified as employee or primary insured under the other coverage and as dependent under this contract, or b. The patient is classified as a dependent under both the other coverage and this contract and l the person under whom coverage is held under the other coverage had greater earnings during the calendar year preceding the year in which the claim involved is incurred than the L person under whom coverage is held under this contract; provided that, notwithstanding earnings, if the patient is a dependent child and persons under whom coverage is held are not married to each other, the Carrier will not be the "Secondary Carrier" if the Carrier is notified prior to payment that the patient is classified as dependent of either the person having custody of the patient or such person's spouse under this contract and as a dependent of a person not having custody of the patient under the other coverage, or c. The effective date of the patient's participation under the other coverage is earlier than the effective date of his coverage hereunder, or when the other coverage has provisions (hereafter referred to as "coordination of benefits i_ excess provisions") which state that it will not provide benefits for the portion of charges cov- ered by the benefits of this contract and the above conditions would make the Carrier the Form No. 2205 ARTICLE IV— PAYMENT OF BENEFITS; COORDINATION OF BENEFITS (Continued) l 9. When benefits have been paid under other coverage, the Carrier shall have the right, in its discretion, to pay over to the issuer or provider of such other coverage any portion of the benefits available under this contract which the Carrier may determine to be due in order -� to give effect to the intent of this Section E and corresponding coordination of benefits pro- visions in such other coverage. The amount so paid shall be deemed to be benefits provided under this contract, and to the extent thereof, the Carrier shall be fully discharged from 1 liability hereunder. 10. If the Carrier is the "Secondary Carrier" under this Section E but is unable to determine the benefits of the other coverage for the charges involved, it will estimate in good faith the benefits of the other coverage and provide the benefits of this contract on the basis of that estimate. Payment under this Subsection 10 shall constitute full discharge of the liability of the Carrier for the charges involved, subject only to adjustment in the event the Carrier later determines the actual benefits of the other coverage prior to the expiration of the period l set forth in Article IX, Section I. } 1 1 l Fnrm Nn 9995 f ARTICLE V- BENEFITS PROVIDED A. BENEFITS FOR BED-PATIENT HOSPITAL EXPENSE and certain Outpatient Hospital Expense When any participant, while covered hereunder, shall incur: 1. Bed-Patient Hospital Expense during each hospital admission in excess of the deductible, if any, stipulated in item 1 of the Schedule, except that the deductible will not be applied to such Expense incurred during a hospital admission primarily for treatment of an accidental injury, or j 2. Outpatient Hospital Expense for treatment of an accidental injury occurring not more than seventy-two (72) hours preceding the outpatient visit, or for minor surgery performed during the course of the outpatient visit, the Carrier will pay benefits equal to the amount determined by application of the percentage stipulated in item 2 of the Schedule to the amount of Expense involved. The excess of the Expense involved over the above determined benefit and deductible is the participant's "Coinsurance Amount." B. BENEFITS FOR OTHER MEDICAL EXPENSE and certain Outpatient Hospital Expense 1. Benefit: When any participant, while covered hereunder and during a calendar year, shall incur: (1) Other Medical Expense and/or (2) Outpatient Hospital Expense for which benefits are not available under Section A of this Article V, in excess of the deductible stipulated in item 4 of the Schedule, the Carrier will pay benefits equal to the amount determined by application of the percentage stipulated in item 5 of the Schedule to such excess, except that the deductible will not be applied to any item of the above Expense that is for treat- ment of an accidental injury which was sustained during the calendar year involved or during the last three months of the immediately preceding calendar year. Such Expense, minus the deductible and the benefits of this Subsection 1, is the participant's "Coinsurance Amount" of such Expense. 2. Exceptions: The following exceptions to the above Benefit will be applicable: a. Any Other Medical Expense or any Outpatient Hospital Expense incurred during the 1 last three months of a calendar year and applied towards satisfaction of the deductible for such calendar year may be applied towards satisfaction of the deductible for the next succeeding calendar year. b. When the total number of participants specified in item 6 of the Schedule under the coverage of one employee have each, individually, satisfied the deductible stipulated in item 4 of the Schedule for a calendar year, any other participants under that employee's coverage will not have to satisfy a deductible for that calendar year. C. BENEFITS FOR COMPLICATIONS OF PREGNANCY If a participant incurs expenses for treatment of complications of pregnancy, benefits under this contract shall be payable on the same basis as for any other sickness. D. BENEFITS FOR MATERNITY CARE Benefits for maternity care under this contract are available only if the obstetrical patient has met the eligibility requirements specified under items 9a or 9b of the Schedule, and then only in accordance with the following: 1. If the obstetrical patient is an employee, the amount of benefits for maternity care shall be determined on the same basis as for any other sickness. c...... i.. none qrn Nn ­06_000—AL479 ARTICLE V— BENEFITS PROVIDED (Continued) 2. Replacement of Coverage: a. Any participant holding Catastrophic Illness coverage issued by Blue Cross of Texas and/or Blue Shield of Texas, immediately prior to his coverage effective date under this 1 contract, who then has an established benefit period in effect, or could upon proper claim have such a benefit period in effect on such date, shall continue to receive benefits for the same condition in accordance with the prior Catastrophic Illness coverage for the remainder of that benefit period or until the maximum benefit has been received, which- ever occurs first, provided, however, that such benefits shall not duplicate, but shall be considered supplemental to the benefits provided by this contract, applying only to the charges in excess of the benefits of this contract, and provided further that any excess for which Catastrophic Illness benefits are so provided shall not be considered as "Coin- surance Amounts" under Section F of this Article V. -� b. If this contract replaces Major Medical coverage issued by the Carrier to the Employer, Major Medical benefits under the prior Major Medical coverage will not be available for any expense incurred on or after the contract date, except as specified in c, below. Any expenses incurred by the participants between (1) September 30 of the calendar year i preceding the contract date and (2) the contract date, which were applied toward satis- faction of the Major Medical deductible of the prior coverage, will be applied toward satisfaction of the Other Medical Expense deductible of this contract. c. If this contract replaces prior Blue Cross and Blue Shield coverage issued to the Em- ployer, benefits for expenses incurred during a hospital admission commencing while the prior coverage was in effect and continuing after the contract date shall be provided 1 in accordance with the terms of the prior coverage until the participant is discharged l from the hospital, as though the prior coverage had remained in effect. d. Maternity Coverage. If: (1) a dependent is pregnant on the effective date of her coverage hereunder, and (2) coverage hereunder replaces any coverage she may have held with Blue Cross and Blue Shield of Texas, and (3) the dependent held'coverage for maternity benefits under the prior coverage, and (4) no benefits are available for such pregnancy under the prior coverage, and (5) benefits for maternity care of the dependent involved have been applied for in item 9b of the Schedule, then the waiting period, if any, specified under item 9b of the Schedule will be reduced by the period of coverage for maternity benefits under the prior coverage. 3. Termination of Coverage Termination of coverage shall not operate to deprive a participant of any benefits to which he would otherwise be entitled for Bed-Patient Hospital Expense and Other Medical Expense incurred during the course of a hospital admission commencing before the date of termina- tion; except that benefits will be provided only for expenses incurred during that hospital admission and prior to the 90th day following the date of termination. j . see Form No. 2207 v STOCK NO. 2207.000-AL479 ARTICLE VI — LIMITATIONS AND EXCLUSIONS The benefits of this contract are not available for: A. A hospital admission for diagnostic or evaluation procedures unless the tests could not have been performed on an outpatient basis without adversely affecting the patient's physical condition or the quality of medical care rendered, provided that Bed-Patient Hospital Expense, other than room accommodation charges, incurred during the hospital admission shall be deemed to be Other Medical Expense and benefits for such expense shall be provided accordingly; B. Any services or supplies rendered in connection with a routine physical examination; or any ser- vices or supplies which are not medically necessary for the diagnosis or treatment of an illness, injury, or bodily malfunction; 1 C. Any hospital services or supplies furnished by any institution or facility other than a member hospital, a nonmember hospital, or a therapeutic center (except that in accident cases, emergency care furnished by any governmental or licensed hospital shall be subject to benefits as provided 1 in Article V); D. Any services or supplies for which benefits are, or could upon proper claim be provided under the Workers' Compensation law, or any other present or future laws enacted by the Legislature of any state, or by the Congress of the United States, or the laws, regulations or established pro- cedures of any county or municipality; provided, however, that the exclusions of this Section D shall not be applicable to any coverage held by the participant for hospitalization and/or medical-surgical expenses which is written as a part of or in conjunction with any automobile insurance policy; E. Any items of Other Medical Expense or Outpatient Hospital Expense incurred for dental care and l treatments, dental surgery, or dental appliances, (1) except for covered oral surgery, or (2) unless J such services are made necessary by accidental bodily injury effected solely through external means and occurring while the participant is covered hereunder; provided, however, that this I Section E shall not be applicable to services and supplies rendered to a newborn child which are necessary for treatment or correction of a congenital defect; F. Eyeglasses including contact lenses, hearing aids, or examinations for the purpose of determining 1 visual acuity or level of hearing; 1 G. Services or supplies for cosmetic purposes, except for the correction of defects incurred through traumatic injuries sustained by the participant while covered hereunder; provided, however, that this Section G shall not be applicable to services and supplies rendered to a newborn child which are necessary for treatment or correction of a congenital defect; H. Travel, whether or not recommended by a physician, except as provided in Article I, Section T, Subsection 9; I. Any services or supplies provided during the course of a hospital admission which commences before the patient is covered as a participant hereunder or any services or supplies provided after the termination of his coverage, except as provided in Article V, Section G, Subsection 3, of this contract; J. Services or supplies rendered to any person who requires them by reason of acting as a donor of any organ or element of his body, unless such person is a participant hereunder; K. Services or supplies not specifically defined as Bed-Patient Hospital Expense, Outpatient Hospital { Expense, or Other Medical Expense; J L. Any medical social services or occupational therapy services; J M. Any services or supplies rendered to any participant for reduction of obesity or weight, including surgical procedures. Form No. 2208 STOCK No. 2208.000-AL479 -,I ARTICLE VII — TERMINATION OF COVERAGE A. The coverage of all participants hereunder shall automatically terminate when this contract is terminated in any manner, as follows: 1. By cancellation on any premium due date, at the request in writing of the Employer fur- nished to the Carrier at its Home Office, not less than thirty (30) days in advance; 2. By default in premium payment, subject to the grace period provided in Article III; 3. By failure of the Employer to maintain enrollment of its employees hereunder at a level of at least seventy-five percent (75%) of the total eligible number, with a minimum enrollment of ten (10) employees; provided that the Carrier shall first notify the Employer of such enrollment deficiency, and provided further that the contract shall not terminate if, within the thirty (30) days following such notification, the deficiency is remedied. In the event of failure to remedy the enrollment deficiency in such case, the date of termination of this contract shall be the last day of the contract month following the month in which the deficiency notification is furnished. B. The coverage of any employee and his dependents included hereunder shall automatically ter- minate upon: 1. The last day of the last period for which his portion of the group premium is paid to the Carrier; provided that the Employer may terminate the coverage of any employee on the last day of any contract month for which premiums for such employee have been received by the Carrier prior to the end of such month and any premiums for such employee that are appli- cable to succeeding contract months will be refunded by the Carrier to the Employer upon request. 2. The effective date of an amendment to this contract which terminates the coverage of any class of employees to which he belongs. C. The coverage of any dependent of an employee included hereunder shall automatically terminate at the end of the contract month in which such dependent ceases to be a dependent as defined in Article I, Section C, of this contract. In the event of termination of coverage under this section due to death of the dependent, the Carrier will refund to the Employer premiums paid for the dependent for contract months subsequent to the date of death, up to tweny-four (24) contract months prior to notification to the Carrier of the death. In the event of termination of coverage under this section for any other reason, refund to the Employer of premiums paid for the dependent for contract months subsequent to the date of coverage termination shall be limited to contract months following the date of notification to the Carrier of the termination of the dependent. D. Under no circumstances shall the Carrier be obligated to,notify any participant of the termination of this contract or of his coverage hereunder. E. Notwithstanding the above provisions of this Article VII, if the Employer is paying an employee's premiums in whole or in part pursuant to the terms of a collective bargaining agreement and in the event of cessation of work as the result of a labor dispute by its employees who are members of the bargaining unit, coverage under this contract for such employees and their dependents hereunder shall terminate on the last day of the contract month in which such cessation of work began; except that coverage under this contract may be continued for such employee and depend- ents for a period of up to six (6) additional contract months, provided that for each such addi- tional contract month: 1. Coverage of at least seventy-five (75%) of the employees, who are members of the bargaining unit and who cease working due to the labor dispute, is maintained; and 2. A single payment for the premiums due from such employees is remitted within the grace period for such premium payment. The Carrier reserves the right to adjust premium rates for such employees which shall be payable for such additional contract months. ARTICLE VIII — CONVERSION PRIVILEGE A. When coverage for an employee is terminated hereunder by reason of cessation of employment, he shall have the right of conversion for all participants included thereunder to new individual coverage as provided for in Section D, below. B. When coverage for an employee is terminated hereunder by reason of death, his or her surviving spouse, if then included as a dependent hereunder, shall have the right of conversion to new indi- vidual coverage for himself or herself and the other previously included dependents as provided for in Section D, below. When coverage for a dependent spouse is terminated hereunder by reason of divorce from the employee, such spouse shall have the right of conversion to new individual coverage for himself or herself as provided for in Section D, below. C. When coverage for a dependent child is terminated hereunder by reason of marriage or attain- ment of age twenty-five (25), he shall have the right of conversion to new individual coverage as I provided for in Section D, below. D. Any person becoming eligible for conversion as provided for in the three preceding sections of this Article VIII may, within thirty-one (31) days after termination of his coverage hereunder, submit application for new individual hospitalization and medical-surgical coverage under the form or forms of contracts then offered by the Carrier to conversion applicants. The contract applied for will be issued, without requirement of evidence of insurability, at the conversion premium rates then in effect. The individual contract will be made effective as of the day after the date of the termination hereunder, and full recognition will be extended to the period of coverage hereunder for the satisfaction of waiting periods and clauses respecting preexisting conditions as may be 1 contained in the individual contract. J _1 J - - ARTICLE IX- GENERAL PROVISIONS i A. CONTRACT; AMENDMENTS: 1. This contract and the Application of the Employer herefor, a copy of which is attached hereto, and the applications of employees shall constitute the entire contract. All statements made by j the Employer or by the employees covered shall be deemed representations and not war- ranties, and no statement made by any employee covered shall be used in any contest or in defense of a claim hereunder unless a copy of the instrument containing the statement 1 is or has been furnished to such person or to his beneficiary. 2. This contract may be amended or changed at any time, subject to the laws of the jurisdiction in which it is delivered, without the consent of the employees covered hereunder or of their 1 beneficiaries, by written agreement between the Employer and the Carrier. Only the President, a Vice President, the Secretary, or an Assistant Secretary of the Carrier has the power to change, modify, or waive the provisions of this contract, and then only in writing done at the Home Office. The Carrier shall not be bound. by any promise or representation heretofore or hereafter made by or to any agent other than specified above. B. INCONTESTABILITY: This contract shall be incontestable after two years from date of issue l except for nonpayment of premiums. C. TIME LIMIT ON CERTAIN DEFENSES: After one year from the effective date of coverage for any 1 employee, no misstatements, except fraudulent misstatements, made in his application for cover- age shall be used to void his coverage or to deny a claim for benefits on account of care rendered after the expiration of such one-year period. D. REINSTATMENT: If default be made in the premium payments for this contract, the subsequent acceptance of such premium by the Carrier or any of its duly authorized agents shall fully reinstate the contract. E. NOTICE OF CLAIM: The employee shall give or cause to be given written notice to the Home Office of the Carrier at Dallas, Texas or its duly authorized agent within thirty (30) days or as soon as reasonably possible after any participant receives any of the services for which benefits are provided herein. Notice given to any member hospital at the time of admission therein as a bed patient shall satisfy this requirement for care rendered by such hospital. F. CLAIM FORMS: The Carrier will furnish to the employee, the hospital, and/or the participant's physician, upon receipt of a notice of claim or prior thereto, such forms as are usually furnished by it for filing proof of loss. If such forms are not furnished within fifteen (15) days after the giving of such notice, the participant shall be deemed to have complied with the requirements of this contract as to proof of loss upon submitting, within the time fixed in the contract for filing proofs of loss, written proof covering the occurrence, the character and the extent of the loss for which claim is made. G. PROOFS OF LOSS: Except for Bed-Patient Hospital care rendered by a member hospital, written proof of loss must be furnished to the Home Office of the Carrier at Dallas, Texas or its duly authorized agent by the employee, except in the absence of legal capacity, prior to the end of the calendar year following the year in which the services or supplies are furnished to the participant involved; provided, however, that any expenses incurred during the last three (3) 1 months of a calendar year shall be deemed to have been incurred during the succeeding calendar J year for purposes of this Section G. J H. TIME OF PAYMENT OF CLAIMS: Benefits payable under this contract for any loss will be paid immediately upon receipt of due written proof of such loss. Form No. 2211 AMENDMENT NO. 1 TO Group Comprehensive Blue Cross and Blue Shield Contract No. 5448 The effective date of this amendment shall be November 1, 1980_ Article III of this contract is amended by deleting the wording of this Article in its entirety and substituting the following: ARTICLE III — PREMIUMS The term "Deposit Premium' as defined in the 11inimum Funding Cost—Plus Agreement between the Employer and Group Hospital Service, Inc. shall constitute "Premiums." } Form No. V-3-002 Article VI of this contract is amended by deleting the wording of Section F in its entirety and substituting the following: aI F. Eyeglasses including contact lenses, hearing aids, or examinations for the prescription or fitting thereof, or examinations for the -� purpose of determining visual acuity or level of hearing; Form No. V-6F-001 _f This amendment shall become effective on the date stipulated above, provided that (1) it is accepted in writing by the Employer; (2) payment of the premium for the first month after the effective date is received by Group Hospital Service, Inc.; and (3) in the event of any alteration of this amendment, such alteration is accepted in writing by Group Hospital Service, Inc. 1 GROUP HOSPITAL SERVICE, INC. 1- •�r.'"' 1— By: W. F. Hachmeister, P��sident Registrar �) Date Form No. 2217 Stock No. 2217.000-N479 { ELIGIBILITY REGULATIONS: Persons eligible to apply for coverage under the contract shall be the 1 employees of the Employer named below 1 who have been continuously employed for not less than 60 _ days. No period of continuous employment shall be required for employees otherwise eligible on the Contract Date ❑Yes Kc No. EFFECTIVE DATES: The effective dates of individual applications are to be handled under the terms of: Standard Option Option I K Option II Other (Specify under Special Provisions) *************END OF SCHEDULE OF SPECIFICATIONS************* CONTRACT DATES: The Contract Date is November 1 19 80 . The first contract anniversary shall be November 1 19_81_-_, whether or not the two dates are separated by twelve months. I MINIMUM ENROLLMENT REQUIREMENTS:The Employer certifies that—91 employees are eligible to make application for coverage at the date of this group application, and agrees that at least 75% of that number (10 minimum) must make application for coverage before the Contract Date, otherwise this applica- tion shall be deemed to have been withdrawn. PREMIUMS:The Employer will provide payroll deduction facilities for the employee's portion of the premium and make consolidated group premium remittances. The following shall be the initial monthly premium rates: Employee, spouse Employee Employee Employee and Employee and and dependent child Only and Spouse Dependent child Dependent children or children $ r $ $ ;4 $ ;r $ The above monthly premium rates shall be subject to change on the first contract anniversary. As of the Contract Date, the amount of Employer contribution is: total employee rate with no contribution toward dependents. SKECIA� PROV�SIO)S: The following stipulations $hall be cogsiderld a pat of this application: men ment oa tote contract has been reviewe by t�e Employer prior to execution of this application and the contents of such amendment are acceptable. Form No. V—SP-001 i 'Minimum Funding Cost Plus Agreement — No Rates Billed. The contract and the coverage provided thereunder shall become effective on the Contract Date stipulated above under Contract Dates, provided that (1) this application is executed in duplicate; (2) payment of the first month's premium is received by Group Hospital Service, Inc.; and (3) in the event of any alteration of this application, such alteration is accepted in writing by Group Hospital Service, Inc. Employer: City of Wichita Falls — Wichita Falls. Texas (Cit nd State) t QackpiprieltriziManager Signed at�'� = '� � _� �• � Witne s: 'c On 7119 - Representative of\�he Carrier Form No. 2213 Page 2 Stock No. 2213.000-N479 This Application Is Hereby Made to GROUP HOSPITAL SERVICE, INC. Dallas,Texas by the Employer named below for a Group Comprehensive Blue Cross and Blue Shield Contract, Form No. CBCBS-2, in accordance with the stipulations set out herein. The Contract Number shall be 5448 SCHEDULE OF SPECIFICATIONS 1 ' in any space means See Special Provisions. N.L. in any space means No Limit.XXX in any space means Coverage Factor Inapplicable or Not Applied For. COVERAGE FACTORS Item BED-PATIENT HOSPITAL EXPENSE BENEFITS No. 1 Deductible per admission XXX 2 Benefit Percentage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . 80 % 3 Maximum number of days available for Psychiatric Care . . . . . . . . . . . . . . . . . . . . . . . . 60 11 OTHER MEDICAL EXPENSE BENEFITS 4 Deductible each calendar year . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . $ 1 50.00 5 Benefit Percentage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . 80 % 6 Number of participants required for Family Deductible . . . . . . . . . . . . . . . . . . . . . . . . . . 3 7 Out-of-Hospital Drugs x❑ Applied For ❑ Not Applied For 8 Psychiatric Care x❑ Applied For ❑ Not Applied For a. Psychiatric Care Benefit Percentage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. 80 % b. Maximum Psychiatric Care Benefit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . .. . $ 1 ,000.00 1 ELIGIBILITY REQUIREMENTS FOR MATERNITY CARE BENEFITS J ("x" in a block means provision preceding is applicable to this contract) 9 a. EMPLOYEES All employees are eligible for Maternity Care Benefits under this contract x❑Applied For ❑ Not Applied For 9 b. DEPENDENTS Spouses of Employees ® Applied For ❑ Not Applied For Dependent Children ❑ Applied For ® Not Applied For are eligible for Maternity Care Benefits under this contract if the obstetrical patient holds coverage for maternity care under this contract continuously from conception to delivery (maternity waiting period). . . . . . . • • . • • • •❑ atdelivery. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . MATERNITY CARE BENEFITS FOR DEPENDENTS 10 a. Bed-Patient Hospital Expense (Applicable to Article V, Section A) ® Regular Benefit Maximum Benefit Per Pregnancy . . . . . . . . . . . . . . . . . . . $ XXX b. Other Medical Expense (Applicable to Article V, Section B) ® Regular Benefit ❑ Maximum Benefit Per Pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ XXX SECURITY PROVISION 11 [m] Applied For ❑ Not Applied For Coinsurance Amount. . . . . . . . . . . . . . . . $ 1 ,000.00 MAXIMUM BENEFITS 12 Maximum Lifetime Benefits available to each participant . . . . . . . . . . . . . . . . . . . . . .. . $ 1 ,000,000 Form No. CBCBS-2-Aop.1 Page 1 Stock No. 2212.000-N479 MINIMUM FUNDING COST-PLUS AGREEMENT This Agreement is entered into by and between GROUP HOSPITAL SERVICE, INCORPORATED and GROUP LIFE & HEALTH INSURANCE COMPANY Dallas, Texas (hereinafter jointly called Blue Cross and Blue Shield of Texas) and CITY OF WICHITA FALLS Wichita Falls, Texas (hereinafter called the Employer) EFFECTIVE: November 1, 1980 for the purpose of determining the ultimate consideration to be paid by the Employer for the coverage provided by Blue Cross and Blue Shield Health Contract numbered 5448, hereinafter called "Health Contract." ARTICLE 1 - DEFINITIONS As used in this Agreement: A. Exhibit means the attached specifications setting out certain particulars of this Agreement or any other subse-quent set of specifications supplied by Blue Cross and Blue Shield of Texas as a replacement exhibit. The specifi-cations or items of the Exhibit may be changed at any time by notifying the Employer of such change and the reasons therefore except that Item III of the Exhibit, Adminis-tration Charge, may be changed only one time in any Contract Year. B. Deposit Premium means the amount of money required by Blue Cross and Blue Shield of Texas for payment of anticipated Paid Claims and anticipated Administration Charge thereon for a period of one (1) month, such amount to be due and payable to Blue Cross and Blue Shield of Texas on or before the fifteenth of each month, the first such month being the month during which this Agreement becomes effective. Deposit Premium will be considered received on the date the money is received in the Dallas, Texas home office. A daily charge equal to .05% of the amount due may be charged for late receipt of Deposit Premium. Each monthly Deposit Premium shall equal an mount calculated in accordance with the formula indicated in Item T t,E the Exhibit. C. Contract Year means each consecutive twelve (12) month period, the first period commencing with the effective date of this Agreement. D. Quarter means each consecutive three (3) month period, the first period commencing with the effective date of this Agreement. E. Stop-Loss Premium means the monthly consideration required by Blue Cross and Blue Shield of Texas for the risk assumed for the Stop-Loss Claims which are indicated "Applied for" in Item V of the Exhibit. Each Stop-Loss Premium is calculated and payable monthly in accordance with the formula indicated in Item II of the Exhibit. A daily charge equal to .05% of the amount due may be charged for late receipt of Stop-Loss Premium. F. Paid Claims means the total of all benefits paid under the benefit- provision of the Health Contract. G. Expected Paid Claims means the total claims that are actuarially expected to be paid each Contract Year under the benefit clause of the Health Contract by Blue Cross and Blue Shield of Texas. Expected Paid Claims will be calculated for each Contract Year in accordance with the formula indicated in Item IV of the Exhibit, provided Item V B is indicated "Applied for." H. Stop-Loss Claims means those Paid Claims for which Blue Cross and Blue Shield of Texas assumes responsibility and risk for payment which is the sum of individual Stop-Loss Claims if indicated "Applied for" in Item V A of the Exhibit and Aggregate Stop-Loss Claims if indicated "Applied for" in Item V B of the Exhibit. 1. If, during any Contract Year, claims paid for an individual certificate exceed the amount indicated in Item V A of the Exhibit, such excess shall be referred to in this Agreement as Individual Stop-Loss Claims. 2. If, during any Contract Year, Paid Claims for that Contract Year less individual Stop-Loss Claims, if any, exceed the results obtained by multiplying Expected Paid Claims for that Contract Year by the percentage indicated in Item V B of the Exhibit, such excess, if any, will be referred to in this Agreement as Aggregate Stop-Loss Claims. I. Administration Charge means the consideration calculated quarterly, in accordance with Item III of the Exhibit, which is required by Blue Cross and Blue Shield of Texas for the administration of the Health Contract. Such consideration will be automatically increased by the amount of premium taxes whenever imposed by lawful authority over and above those applicable on the effective date of this Agreement. ARTICLE II - SETTLEMENTS A. Quarterly Settlement. Within thirty (30) days following the end of each quarter, Blue Cross and Blue Shield of Texas will furnish the Employer a report for that quarter detailing Deposit Premium, Paid Claims, Administration Charge and all other data required for a quarterly settlement. If the report reflects that Deposit Premium exceeds Paid Claims plus Administration Charge, the excess shall be due the Employer. If the report reflects that Paid Claims plus Administration Charge exceeds Deposit Premium, the excess shall be due Blue Cross and Blue Shield of Texas. Interest calculated in accordance with Item VI of the Exhibit will be added to each excess payment amount made either to the Employer or Blue Cross and Blue Shield of Texas. No accounting will be made for Stop-Loss Premiums. B. Remittance. Within ten (10) days of receipt of the Quarterly Settlement provided for above, the Employer or Blue Cross and Blue Shield of Texas, as the case may be, shall remit payment of such excess. A daily charge equal to .05% of the amount of excess due may be charged for late remit- tance. C. Annual Stop-Loss Settlement. If Item V A of the Exhibit is indicated "Applied for", an Individual Stop-Loss Settlement will be made annually within forty-five . (45) days following the end of each Contract Year during which this Agreement was in effect in accordance with paragraph 1, below; provided, however, if the Health Contract or this Agreement is terminated on a date other than a contract anniversary, a settlement will be made under paragraph 1, below, for that portion of any Contract Year immediately preceding termination. If Item V B of the Exhibit is indicated "Applied for", an Aggregate Stop-Loss Settlement will be made annually within forty-five (45) days following .the end of each Contract Year during which this Agreement was in effect in accordance with paragraph 2, below; provided, however, if the Health Contract or this Agreement is terminated on a date other than a contract anniversary, in no event will a settlement be made under paragraph 2, below, .for that portion of any Contract Year immediately preceding termination. 1. Individual Stop-Loss Settlement. Blue Cross and Blue Shield of Texas will prepare a report listing Individual Stop-Loss Claims, if any, by certificate. This report together with a payment for all Individual Stop-Loss Claims, if any, will then be forwarded to the Employer. 2. Aggregate Stop-Loss Settlement. If a settlement is required to be made under paragraph 1, above, Paid Claims used for this settlement shall not include individual Stop-Loss Claims, if any. If Paid Claims for the Contract Year involved exceed Expected Paid Claims for the same Contract Year multiplied by the percentage indicated in Item V B of the Exhibit, the amount of such excess shall be forwarded to the Employer. If the reverse is true, the Aggregate Stop-Loss shall not come into effect and no payment will be due under this paragraph. D. Termination. Upon termination of the Health Contract and/or this Agreement, the time intervening between the end of the period covered by the immediately preceding report required under Section A, above, and the termination date regardless of the number of months involved, shall be deemed a quarter and a settlement made as provided for in Article II, Sections A and B, above. The Employer shall continue to remit Deposit Premium for three (3) consecutive months subsequent to the effective date of termination to provide for the remaining expected paid claim liability and Administration Charge. For the purpose of this section, the monthly Deposit Premium will be an amount equal to the Deposit Premium payable for the month preceding termination; and the Administration Charge will be an amount equal to the Administration Charge in effect for the month preceding termination. At the end of the seventh (7th) month following termination, Blue Cross and Blue Shield of Texas will prepare a tentative settlement report for the six (6) month period following termination, and will refund to the Employer any Deposit Premium which is not considered by Blue Cross and Blue Shield of Texas to be reasonably necessary to cover the cost of future Paid Claims plus Administration Charge. Blue Cross and Blue Shield of Texas reserves the right to bill the Employer for an additional amount at this time (an Interim Billing) in the event any remaining Deposit Premium is considered not adequate to cover the cost of future Paid Claims plus Administration Charge. The Annual Stop-Loss Settlement does not apply to this section. A final report will be furnished the Employer twenty-seven (27) months after termination. This report will detail Deposit Premium, Paid Claims, Administration Charge, Refunds and Interim Billings, if any, applicable for the period commencing with the date of termination to the date the report is rendered. If the report reflects that Deposit Premium less Refunds plus Interim Billing Payments, if any, exceeds Paid Claims plus Administration Charge, the excess shall be due the Employer. If the report reflects that Paid Claims plus Administration Charge exceeds the sum of Deposit Premium less Refunds plus Interim Billings, if any, the excess shall be due Blue Cross and Blue Shield of Texas. Blue Cross and Blue Shield of Texas reserves the right to bill the Employer for Paid Claims plus Administration Charge for any claims paid subsequent to the final settlement. Any amount due under this section shall be paid in accordance with Article II, Section B, above. ARTICLE III - GENERAL PROVISIONS A. Contract Amendments. Article III of the Health Contract is hereby amended, to provide that payment of the Deposit Premium as defined in Article I, Section B of this Agreement and the quarterly payments as provided in Article II, Sections A and B of this Agreement shall constitute "premiums" as used in such Article of the Contract. B. Allocation. Blue Cross and Blue Shield of Texas have a reciprocal agreement under which they will allocate monies received, and they agree that the Employer shall have no responsibility for or interest in such allocation. C. Right to Terminate. This Minimum Funding Cost-Plus Agreement will termi- nate if the Health Contract terminates and may be terminated by either party pursuant to written notice given by either party to the other not less than forty-five (45) days in advance of the termination date. Upon such termination, subsequent settlement shall be effective in accordance with the provisions of Article II hereof. Witness our hands this �� day of ��` ' , 19 For Group Hospital Service, Incorporated and Group Life & Health Insurance Company: W. F. achmeister, President For CITY OF WICHITA FALLS tuar Bach, City Manager EXHIBIT Specifications for Contract Year Beginning November 1 , 19 80 CITY OF WICHITA FALLS GROUP NUMBER: 5448 Item I -- Deposit Premiums will be calculated monthly by multiplying the sum of the figures shown in the columns headed "Paid Claims" and "Administration Charge" for the month involved by the number of Certificates in force on the first day of that month. Item II -- Stop-Loss Premium will be calculated monthly by multiplying the figures shown in the column headed "Stop-Loss Insurance" for the month involved by the number of Certificates in force on the first day of that month. Monthly Payment Schedule Per Certificate Deposit Premiums for Anticipated Payment Administration Stop-Loss Month Paid Claims Charge Insurance Total 11/80 2.00 0. 13 0.67 2.80 12/80 19.58 1.28 0.67 21.53 1/81 28.51 1.87 0.67 31.05 2/81 36.77 2.41 0.67 39.85 3/81 39.44 2.59 0.67 42.70 4/81 42.22 2.77 0.67 45.66 5/81 43.48 2.85 0.67 47.00 6/81 44.55 2.92 0.67 48. 14 7/81 45.39 2.98 0.67 49.04 8/81 46.35 3.04 0.67 50.06 9/81 47.09 3.09 0.67 50.85 10/81 47.32 3. 10 0.67 51.09 Item III -- Administration Charge for the indicated Contract Year shall be 6. 56% of Paid Claims. Item IV -- Expected Paid Claims for the indicated Contract Year will be cal- culated by completing the following schedule. Risk (A) ( ) (C) Exposure Monthly Expected Paid Total Expected Paid Months Certificate Count Claims Per Certificate Claims For Contract Year (1 ; 11/i?0 $40.69 12/80 36. 98 1/8t 47.84 2181 42. 56 3/51 46. 26 4/81 43. 59 5/81 43. 12 6/81 41.82 7/81 39.85 8/81 34.86 9/81 22.80 10/81 2.43 Expected Paid Claims - Incurr.ed During Contract Year $ (2 Expected Paid Claims - Incurred Prior to Contract Year $ -(�- Total Expected Paid Claims $ Footnotes (1 ) Column (C) equals Column (A) times Column (B) . (2) Equals siunmation of Column (C) . Item V -- Stop-Loss Options A. Individual Stop-Loss Applied for. . All claims paid per certificate during the indi- cated Contract Year which are in excess of. $ X Not applied for. R. Aggregate Stop-Loss X Applied for. The amount of Paid Claims during the indicated Contract Year which exceeds120 % of the Expected Paid Claims.' Not applied for. Item VI -- Forty-five (45) days interest at the rate of 87 per anniun will be credited on all excoss settlement imounts payable under Article II, Section A of this Agreement, while this Agreement i_s in effect. gnature. of Croup Executive Date Stuart Bach, City Manager Sttnatni ( -I;l_ue Noss ikprosvntativc Date f f-- fAN­ VI)A' GROUP HOSPITAL SERVICE, INC. (Herein called the Carrier) Dallas, Texas has issued this Non-Cancellable EXPERIENCE RATED GROUP DENTAL CONTRACT (Herein called the Contract) f to the Employer named in the application herefor and thereby the Carrier agrees to provide the benefits detailed herein, all in accordance with the conditions and provisions hereof, including those set out on the following pages which are a part of this contract as fully as if recited over the signatures hereto affixed. This contract is issued in consideration of the application herefor made by the Employer and l of the timely payment of premiums as provided for herein. It will become effective on the Contract Date stipulated in such application and will be continued in force, subject to the Employer's right of termination, for so long as the minimum employee participation is maintained, as set out in Article VII. IN WITNESS WHEREOF, the Carrier has caused this contract to be executed at its Home Office [ in Dallas, Texas. L L2Q President Secretary Countersigned: � � 0• Registrar Form No. GOC•2 2800.000-aLseo f - ARTICLE I-DEFINITIONS AS USED HEREIN: A. EMPLOYER means, in addition to the person, firm or institution named in the application herefor, any subsidiary or affiliate listed as such under Eligibility Regulations in the Schedule. B. EMPLOYEE means a person who regularly renders personal services, not less than one hundred twenty (120) hours per month in the business of the Employer, and who (except in the case of a proprietor, partner, or corporation officer or director) is compensated for such services by salary or wages. C. DEPENDENT means: 1. An employee's spouse or L 2. Any unmarried child, who is either under twenty-five (25) years of age or disabled; pro- vided that in the case of a disabled child twenty-five (25) years of age or older, such child is dependent upon the Employee for more than one-half of his support as defined by the Internal Revenue Code of the United States. "Disabled" means any medically determinable physical or mental condition which prevents the child from engaging in self-sustaining employment; provided that the disability com- mences prior to such child's attainment of age twenty-five (25) and that satisfactory proof of such disability and dependency is submitted by the Employee within thirty-one (31) days following such child's attainment of age twenty-five (25). "Child" means the natural child of the employee; a legally adopted child (including a child living with the adopting parents during the period of probation); a stepchild residing in the Employee's household; or a child permanently residing in the household of which the Employee is the head and to whom the Employee is legal guardian or related to the child by blood or marriage. As a condition to the continued coverage of a child as a disabled Dependent beyond the age of twenty-five (25), the Carrier shall have the right to require periodic certification of the child's physical or mental condition but not more frequently than annually after the two-year period following the child's attainment of age twenty-five (25). D. PARTICIPANT means an Employee or a Dependent, as above defined, whose application for coverage hereunder has been accepted by the Carrier. E. CONTRACT MONTH means each succeeding monthly period, beginning on the contract date. L F. CONTRACT YEAR means each succeeding twelve-month period, beginning on the effective date of coverage hereunder for the Employee concerned, whether the care invoking benefits is rendered to the Employee or to a Dependent under his coverage. LG. CONTRACT ANNIVERSARY means the month, day and year specified in the Application for this contract and the corresponding date in each year thereafter for as long as this contract is in force. LH. SCHEDULE means the Schedule of Specifications appearing in the Employer's Application for this contract, or the latest of any revised schedules mutually agreed to by the Employer and the Carrier to replace one previously in effect, provided that if more than one Schedule of Specifications is in effect under this contract, the term shall mean, for each Employee covered hereunder, and for each Participant under his coverage, the Schedule of Specifica- tions which has Eligibility Regulations that are applicable to such Employee. LI. COVERED DENTAL EXPENSES means the professionally recognized Dental services or appliances provided to a Participant by a Dentist on or after the effective date of coverage for which the Employee acquires an obligation for payment. L b Form No. 2801 2801.000-AL679 l ARTICLE II-ELIGIBILITY FOR COVERAGE; EFFECTIVE DATES A. ELIGIBILITY FOR COVERAGE 1. Any Employee of the classifications described under Eligibility Regulations in the Schedule shall, upon the later of completion of the length of service therein specified or the contract date, become eligible to apply for coverage hereunder for himself or for himself and his family members as Dependents. 2. Family members acquired after the effective date of the Employee's coverage shall become eligible on the date the family member becomes a Dependent as defined in Article I, Section C, of this contract. 3. Coverage of the Employee shall be a condition precedent to coverage of his eligible Dependents. B. APPLICATION FOR COVERAGE Coverage of each eligible Employee or Dependent shall be contingent upon the Employee's making application therefor in accordance with the approved procedures established by the Carrier; thereupon, subject to acceptance by the Carrier, coverage shall become effective in accordance with the following sections of this Article II. C. EFFECTIVE DATES—EMPLOYEES If the application is for coverage of an Employee or of an Employee and his eligible Dependents, and 1. If the Employee is eligible on the contract date and if the application is made prior thereto, the coverage shall become effective on the contract date. 2. If the Employee becomes eligible on or after the contract date and if the application is made after the contract date but within the first thirty (30) days following the date of eligibility, and a. If "Standard Option" is specified under Effective Dates in the Schedule, the coverage shall become effective on the Employee's date of eligibility; b. If "Option I" is specified under Effective Dates in the Schedule, the coverage shall become effective on the second premium due date following the date that the applica- tion is made; c. If "Option II" is specified under Effective Dates in the Schedule, the coverage shall become effective on the first premium due date following the date that the application is made. 3. If the application is made more than thirty (30) days after the date such Employee becomes eligible, the coverage shall become effective on the succeeding contract anniversary which occurs at least thirty (30) days after the application is made. 4. Regardless of the above subsections of this Section C, if "Other" is specified under Effec- tive Dates in the Schedule, coverage shall become effective as set forth thereunder. L k , Form No. 2802 - 2802.000-AL879 i ARTICLE III—PREMIUMS A. The premium rates initially effective shall be shown under "Premiums" in the Employer's Application, and continuance of the coverage hereunder shall be contingent upon payment of the premiums by the Employer at the Home Office of the Carrier in Dallas, Texas, in accordance with the following provisions: the first premium is due on the contract date; -� subsequent premiums are, during the continuance of this contract, payable in advance. No payment shall be accepted by the Carrier which does not represent a total monthly premium. 1 B. This contract shall be nonassessable. It does not share in the earnings of the Carrier, but the Carrier reserves the right to change the premium rates on any contract anniversary, as applicable to the succeeding year, commencing with the contract anniversary stipulated in 1 the Application, provided that: I 1. If the Carrier does not change the premium rates on any of the above Contract Anniver- saries, it shall have the right to change premium rates once on any premium due date -1 occurring between such Contract Anniversary and the next succeeding Contract Anniver- sary and such change shall be applicable to the Contract Months succeeding such premium due date; I2. In the event price controls are established by the state or federal governments while this contract is in effect, the Carrier reserves the right to adjust premium rates on any premium due date occurring between the date of imposition of such controls and the Contract Anniversary following termination of such controls. Any such change shall be made uniformly applicable to all Employees within any subgroup l or other classification under this contract. fJ C. Premiums may be paid on a monthly, quarterly, semiannual, or annual basis as the Employer may elect, but without discount. Unearned premiums for Employees whose coverage here- under terminates at other than premium due dates shall be calculated and refunded from the end of the Contract Month during which the Employee ceased to be eligible for coverage hereunder. D. The premium to be paid hereunder shall be determined by multiplying the number of Employees covered for each classification by the rate then applicable for that classifcation, 1 and totalling the extensions thus obtained; provided, however, that for Participants whoss coverage becomes effective in accordance with Article If on other than the first day of a Contract Month, no premium shall be due for any portion of the Contract Month in which i the coverage becomes effective. E. A grace period of thirty-one (31) days, without interest charge, shall be allowed for the pay- ment of each premium except the first. If any premium is not paid within the grace period, this contract shall terminate at the end of such grace period, except that the contract shall terminate at an earlier date (which is not prior to the end of the period for which premiums have been paid) provided the Employer shall have given the Carrier written notice of such earlier date of termination in accordance with the provisions of Article VII, Section A. If the contract terminates during or at the end of the grace period, the Employer shall be liable to the Carrier for payment of a pro rata premium for the time the contract was in force during the grace period. The allowance of the grace period is applicable only to the total premium, and shall not be construed so as to extend the coverage of any Employee for whom a premium has not been paid as a part of the group remittance. o ARTICLE IV-PAYMENT OF BENEFITS; COORDINATION OF BENEFITS A. Subject to the qualifications, limitations and exclusions set forth herein, when obligated for the provision of benefits hereunder, the Carrier will pay the Dentist's charges for services rendered in accordance with Article V, provided, however, that: 1. If payment is based on a Schedule of Indemnity Allowances, such payment shall not 1 exceed the amount specified in the Schedule of Indemnity Allowances, or 2. If payment is made on a Usual, Customary and Reasonable Charge basis, the Carrier 1 reserves the right to predetermine any services for which benefits are payable, and 3. In all events such services must be performed by a Dentist as defined herein. 1 It is understood and agreed that the benefits as set out in Article V are not intended to and do not fix the value of the services of the attending Dentist nor in any way relate to or regulate such value; that the attending Dentist is privileged to make his regular charges and that the 1 stipulated amounts are merely to apply as credits thereon. All payments for Dental Proce- dures as set forth in Article V are payable to the Dentist rendering the service or the Employee as the Carrier may elect. Such payment in either event shall constitute full discharge of all 1 responsibility of the Carrier to the Employee for benefits on account of such services. B. Any benefits hereunder, payable to the Employee, shall, if unpaid at his death, be paid to the -� Dentist or to the surviving spouse of the Employee, as beneficiary; if there is no surviving spouse, then such benefits may be paid to the Employee's estate. C. The benefits provided hereunder are not assignable. D. It is hereby declared to be the intent of the Employer and the Carrier that the availability of the benefits herein specified shall be contingent upon the absence of other coverage. Any 1 other contract or policy or employee welfare benefit plan under which the Participant holds I protection for Dental expenses by virtue of his membership in or relation to a particular group shall be considered "other coverage" within the meaning hereof, whether the benefits are in the nature of indemnity or prepaid services. The term shall likewise be deemed Jto include any governmental program existing by statutory authority under which he is entitled to Dental benefits. The term shall not be deemed to include any coverage held by the participant for Dental expenses which is written as a part of or in conjunction with any automobile casualty insurance policy. When, therefore, other coverage applies, the benefits of this contract shall be coordinated therewith and determined in accordance with the following subsections of this Section D: I 1. The benefits of this contract shall be modified by the provisions of this Section D only when the Carrier is the "Secondary Carrier."The Carrier is the "Secondary Carrier" when the other coverage has provisions which state that it will provide its full benefits regardless of the benefits of this contract or when the other coverage has provisions corresponding to the provisions of this Section D and: J a. The patient is classified as Employee or primary insured under the other coverage and as Dependent under this contract, or b. The patient is classified as a Dependent under both the other coverage and this con- tract and the person under whom coverage is held under the other coverage had greater earnings during the calendar year preceding the year in which the claim —� involved is incurred than the person under whom coverage is held under this contract; provided that, notwithstanding earnings, if the patient is a Dependent child and persons 1 of e}ej oid Aidde of powaap aq ll!m Aaq} ',unowe pa}eoolleun ue ui aoinaas 10 waIrauo ue 1 q avow Jo} Jo saoinaas POZiw911 uie}Jao Jo} 96eaan00 jaq;o Aq papinoad aje slijaueq uagM •g 1 •;oealuoo siq,jo slijauaq PBUIWJ919p anoge eqj of lenbe sli;auaq apinoid ll!M aauaeo aqj 'panIonui sa6Jego 041 1 10 (%og) lueoiad Ajpj uegj ssal jenbe pei}uoo siq} jo slijauaq pauiwaaIap anoge aq;11 -o •96ea9noo a8410 aq}}o s}i jaueq pauiwaajap anoge aql 19no pan,onui sa6ae40 aq; 10 ssaoxa agl Jo lowwoo sigl jo sli;auaq pauiwaajap anoge aql 10 jassal aqj of lenbe s;ilauaq apinoid ll!m aaiaaeo agj 'panjonui sa6ae40 aq}10 KOS) ;uaoaad All!j ueq} ssal lenbe a6ea9no0 aag}o eq}japun s;ilauaq pauiwaa;ap anoge agj;1 •q 1 •panJonui s96Je40 9q, 10 (%0q) juawed Ajj!j o; lenbe slijaueq apinoid ll!m aauaea 941 'panIonui s96ae40 9141 10 (%og) }uooaad Alj!j paeoxe ao jenbe goes 96eaan03 a9410 aqj pue ;oei;uoo sig} gjoq japun s;ilaueq PDUIWJ910p anoge aqj 11 •e 1 •paupielap eq Isii; ll[M uoisinoid siq} }o aouasqe eq} ui panjonui sa6ae40 aqj JOI papinoid ueaq anEq pinoM ;eql 96ea9no0 Jagjo aqj pue joealuoo siq} gloq jo s}ijauaq aqj 'suoisinoid ssaoxa slilaueq I10 uoi;euipa000 seg 06eaan03 aagjo aqj pue „aai1aeo Aiepuooes„ aqj si aaiaaeo ag; uagM •g •96ea9no3 aaq}o jo eouesge aqj ui aapunaaaq 1 algeAed aq p1noM goigm sii}auaq jelo} jo ;unowe aq} aseajoui of pana;suoo aq uoiloas siq; 10 suoisinoid ag; l'Iegs Juana ou ui Iegl 'aanaMog 'papinoid '.swali gons aol sabaego ag; jo aapuiewai eq; lied J!JM aaiaaea ag} pue '96ea9no0 Jaq}o Jo '109'aq n aloi;iy aapun papin -oid si I!Ieueq Aue 4014M ao; saoinJas IeJuao 10 swaji JJe 10 sa6Jego aq} woal palonpap aq 11e4s 96eaanoo aaglo aq; }o siiIauaq aq; 'suoisinoid ssaoxa s;ilauaq jo uoileuip -a000 aneq IOU saop 96eaano3 Jagjo ag} pue „jaijjeo AiepuooaS„ eqj si joined 041 uagM -jean(iepualeo duo Aue 6uianp jued'O'Ved a o} pagsiwnj saoiMas aq} 01 uol;e19J ui apew eq llegs a uoi;oaS siq; japun sli;aueq jo uoileuiwja;aa •g }oea}uoo pjaueq Ieoibins-leoipaw-uoilezileIidsog legl japun saoinaas asoq; jo} alge -Ilene WE sl!leueq f1 joeiluoo sig; aapun ajgejiene we s}i}auaq goigM JOI saoinaas Cue jo; „aaiajea AjepuooaS„ aqj paaapisuoo aq llegs jauaea eq} 'aaAojdw3 OW 01 'sexal 'seIIea 'Auedwoa eoueinsul WIeaH V ap-1 dnag pue •ouI 'aoinaaS lelidsoH dnoaE) Aq ao aaiaiea aqj Aq panssi si joei;uoo I!Iauaq leoibins-leoipaw-uoilezile}idsoq a}eiedes a Juana agl ul •Z 'paaapuaa aae apew si wieJo goigM ao}saoinaas eqj alep aqi uo aoualsixe ui s}oe} aql jo siseq eqj uo paupialap aq IIegs o uoiloas sigj 10 suoisinoid eq} ;o A}ijigeoijdde aql „-jaiajea Aiepuooas„ aq} jaiaaeo aq} aNew p1noM suoijipuoo anoge aq} pue }oealuoo sigl jo sli}auoq agl Aq paaanoo s86Me40 10 I uoilaod eqj aol slilauag apinoid ;ou ll!m i! legl aIe}s 4014M („suoisinoid ssaoxa s}i}auaq ;o uoi}euipa000„ se 01 paaaajaa aa}}eaaaq) suoisinoid seq 96ejanoo a91410 aqj uagM ao aapunaaaq 86eaano0 siq 10 a;ep an1109119 ag;ueq; J81JJe9 sl 96ea9no0 aaq;o aqj aapun uoi;edioilaed sjuaiJed aqj jo a;ep an1108119 aql •o Jo '96eaanoo aagJo eqj japun juailed aql jo Apo;sno 6uineq ;ou uosaad a jo juapuadaa a se pue loealuoo sig; japun asnods s,uosiad gons jo juai}ed aqj jo Apo;sno 6uineq uosaad aql aaglia jo ;uapuadaa se paipsselo si ;uailed eqj leq} }uawAed o; aoud paiplou si aaiaaea aql ;i „jaiaaeo AaepuooeS„ eqj aq IOU ll!m jaujea eq} 'aaglo goes 01 paiaaew IOU aye p194 si 058Janoo wogM japun (penuiluoo) S11d3N38 d0 N011VNIaH003 !SlId3N38 dO 1N3W kVd — Al 3-1O11W I - ARTICLE IV — PAYMENT OF BENEFITS; COORDINATION OF BENEFITS (Continued) all such items.When a deductible amount applies to the benefits of other coverage,'it shall be deemed to apply pro rata to each of the benefit factors thereunder. 7. The Carrier assumes no obligation to discover the existence of other coverage or the benefits payable under it if discovered, but only to give effect to the provisions of this Section D in accordance with information furnished it by an authoritative source. It shall, however, be entitled to obtain and/or to release such information as reasonably necessary to give effect to these provisions, without the consent of or notice to any person; and any person claiming benefits hereunder shall, as a condition precedent to his right of recovery, furnish to the Carrier full information concerning the existence of other coverage and the benefits thereof. 8. The Carrier shall be entitled at any time to recover benefits paid in excess of the obligation as determined under the provisions of this Section D, irrespective of or to whom such benefits were paid, from an issuer or provider of the other coverage, or any person or firm to or for whom such payment was made, or from any combination of such sources. 9. When benefits have been paid under other coverage, the Carrier shall have the right, in its discretion, to pay over to the issuer or provider of such other coverage any portion of the benefits available under this contract which the Carrier may determine to be due in order to give effect to the intent of this Section D and corresponding coordination of benefits pro- visions in such other coverage. The amount so paid shall be deemed to be benefits provided under this contract, and to the extent thereof, the Carrier shall be fully dis- charged from liability hereunder. 10. If the Carrier is the "Secondary Carrier" under this Section D but is unable to determine the benefits of the other coverage for the charges involved, it will estimate in good faith the benefits of the other coverage and provide the benefits of this contract on the basis of that estimate. Payment under this Subsection 10 shall constitute full discharge of the liability of the Carrier for the charges involved, subject only to adjustment in the event the Carrier later determines the actual benefits of the other coverage prior to the expiration of the I period set forth in Article VIII, Section I. f L L E_ 0 Form No. 2842 gone nnn. n o-.� ARTICLE V-DENTAL BENEFITS PROVIDED Section A COVERED DENTAL EXPENSES 1. BASIC BENEFITS If item 1 of the Schedule is indicated "Applied For," the following Covered Dental Expenses will be paid up to the Dentist's charge, not to exceed: (a) If item 2 of the Schedule is indicated, the percentage of the Dentist's Usual, Customary and Reasonable charge (UCR) as indicated in item 3 of the Schedule, or (b) If item 4 of the Schedule is indicated, the indemnity allowance of either High, Medium, or Low as indicated in item 5 of the Schedule. a. ORAL EXAMINATIONS, including treatment plan, as follows: Usual, Customary Schedule of Code Procedure and Reasonable Indemnity Allowance High Medium Low 00110 Initial Oral Examination (The UCR $ 9.00 $ 7.00 $ 5.00 first time a patient is seen by the current Dentist) 00120 Periodic Oral Examination UCR 7.00 6.00 4.00 (Routine follow-up examina- tions) limited to one examina- tion within any consecutive six month period 00130 Emergency Oral Examination UCR 8.00 6.00 5.00 (Examinations necessary as a result of injury) Benefits for Oral Examinations in conjunction with palliative treatment or adjustments of prosthetic or orthodontic appliances are not payable. Benefits for Oral Examinations which are limited in scope, such as an endodontic examination, are not payable. b. PERIAPICAL AND BITEWING RADIOGRAPHS, within the specified time limits, as follows: 00210 Intraoral—Complete Series UCR $ 21.00 $ 17.00 $ 13.00 of all Tooth Areas (including bitewings). One series within any consecutive three (3) year f period L 00220 Intraoral—Single Film, First UCR 4.00 3.00 2.00 Film (A single radiograph of a specific tooth or area) 00230 Intraoral —Each Additional UCR 2.00 2.00 1.00 Film (Additional films for com- pletion of diagnosis or treatment 00240 Intraoral—Occlusal Film (A UCR 6.00 5.00 4.00 L film used for locating and orienting fractures, impacted and unerupted teeth, foreign bodies, extensive cysts and tumors and stones in the salivary ducts and glands) L Form No. 2805 2805.000—A L 679 f - f I (09Z00 pUe 09Z00 sapoo jo uolleueldxa aaS) wl!3 AananS `euog leloed pue IInNS 00'£L 00TL 00'ZZ uon leaale-1 pue aoualueoaalsod 06ZOO f 00'0l 00't,L 00'LL bon sw113ano3 —sbu!nnal!8 VLZ00 l 00'9 00'0l 00'£L uon swl!d amyl—sbulm9l!8 £LZOO 00'9 00'L 00'6 uon swl!3 Oml—s6ulm@M3 ZLZOO (uolloalap sepeo [glaal aql ueemlaq] lewlxoadaalui aol glaal agl;o suollaod umojo aql to abewi we ulelgo of pasn wl!; gdea6o!pe)j) wl!d leuOPIPPV goe3 00'£ 00'17 00*9 uon wl!3 }saki `816ulS—6ulMal!8 OLZ00 wild 00'9 00T 00'0L )don 1eu011!PPV 40e3—leaoealx3 09ZOO (sainsodxo leaoealu! Aq pagoew aq louueo legi seaae jo pue seaie aa6ael lnoge uollewaol.u! 6u!ulelgo aol glnow aql jo ap!slno peoeld wl!l aql ql!m apew ainsodxa f_ 00'L 00'0L 00'ZL uon uV) wlld lsald— leaoealx3 09ZOO Lwnipew 461H aouemoliv AI!uwapul olgeuoseaa pue ainpaooad OPOO ;o alnpaps Aiewo;sno Ilensn (penuiluo0) a3alA0ad S11d3N38 'IdiN3a—A 3-IOIIUV i ARTICLE V—DENTAL BENEFITS PROVIDED (Continued) l Usual, Customary Schedule of Code Procedure and Reasonable Indemnity Allowance High Medium Low 00310 Sialography (Intraoral and UCR $ 24.00 $ 19.00 $ 15.00 extraoral film usually used with dye contrast for the detection of blockage in the salivary ducts) 00321 Temporomandibular Joint UCR 20.00 16.00 12.00 (Single Film) (Extraoral film used for detection of abnormalities of the TMJ) I00330 Panoramic— Maxilla and UCR 21.00 17.00 13.00 Mandible—Single Film (A single continuous exposure of the oral cavity on an extra-oral film [a complete series]) Will be considered a full mouth if I accomplished in conjunction with bitewings 00340 Cephalometric Film (Extraoral UCR 20.00 16.00 13.00 film used by prosthodontists, oral surgeons) Not covered when used in conjunction with an Orthodontic Treatment Plan Full-mouth radiograms are limited to one in any consecutive three (3) year period and bite- wing radiograms are limited to one (1) in any consecutive six (6) month period. The proce- dures for benefit codes 00220 and 00230, when accomplished in conjunction with one another, will be deemed full-mouth x-rays and the combined schedule of indemnity for those proce- dures shall not exceed the amount payable for a full-mouth radiogram. c. TOPICAL FLUORIDE APPLICATION (for Participants under age 19) limited to one appli- cation in any consecutive six (6) month period, as follows: 01210 Topical Application of Sodium UCR $ 6.00 $ 5.00 $ 4.00 Fluoride— Four Treatments ` (Excluding prophylaxis) L 01211 Topical Application of Sodium UCR 16.00 13.00 10.00 Fluoride— Four Treatments (Including prophylaxis) 01220 Topical Application of UCR 11.00 9.00 7.00 Stannous Fluoride—One Treatment (Excluding prophylaxis) L L_ Form No. 2806 2806.000—AL679 I (OZ9S0 gl!M uolloun(uoo ul pasn sl apoo slgi) glooi goe3 00'9 00'8 00'0l ion —glaai leuolllppy aoeldaa 0£990 (Ajoleaogei ao aolllo ul) glooi auo aoeldaa pue ainlua4 lellaed 00'sl 00'6L 00'j7Z uon io olaldwoo ua)loa8 aledaa OZ990 (Ajoleaogel ao a01110 ul) pabewed glaai ON—ainluaa MIMd 00'ZL 00'9L 00'OZ aOn ao aloldwoo ualloig aledaa 0L990 00'9 00'L 00'6 aOn sumoao luauaaoaa OZ6Z0 (SAeluo 00'9 $ 00'L $ 00'6 $ ion sapnloul) sAelul luawaoaa 0L6Z0 :snnollol Se `S3aniN30 dO alyd3a a •ainp000id slxelAgdoid aql ulgllm papnloul aq of poweap aq Ilegs slxelAgdoid e se Aup awes oql uo pue gl!m uollounfuoo ul pawaolaad 6ulleos pue o6ellaino 'aseas!p leluopoped to luawleaai to asinoo a to lied se powiolaad 6u!ueld loos pue abellaino aol algellene lou We sl!laua8 (aa6unoA ao 00'9 00'8 00'0L uon a6e to saeaA6L) uaaPl!g3 OZLLO 00'L $ 00'OL $ 00'ZL $ uon sllnpV OLLLO :smollol se `po!aad gluow (9) xls an!lnoesuoo Aue ul s!xelAgdoid auo of pollwll `6ulgsllod pue 6ulleos `6uluealo 6ulpnlou! `SIXyIAHdOad 'P 'paJanoo lou Si slelaalew anlleaolsaa ul ao/pue alsed slxelAgdoid ul appondl }o asn aql •paaanoo IOU WE 901110 s,IsiIuap aqi }o apisino asn aol appong pue uoneaolsaa leUll a to luawooeld of aoud glool a to uolliod paaedaid eql of apuonll to uolleo!ldde leoldoi I (s!xujAgdoad l 6u!pnloul) luawleaai auo—alegdsogd aplaonld L00'L L 0017L 00'L L uon p!oy to uolleollddy leoldoi L£Z LO (slxelAgdoid 6ulpnlox3) luawleaai L auo—alegdsogd aplaonld 00'8 00'0L 00'£L uon play to uolleollddy leoldoi 0£ZL0 (slxelAgdoid L 6ulpnloul) luawleaai auo—aplaonld snouuelS 00'0L $ 00'£L $ 00'9L $ uon to uolleollddy leoldoi LZZLO nno3 wnipaw 46lH aouemolid Aliuwapul e1geuoseaa pue ajnpaooad apoo to ainpagoS Ajewolsno `Ienstl (panui;uo0) a3a1A0bd S11d3N38 1d1N3a—A 3l311MV i ARTICLE V-DENTAL BENEFITS PROVIDED (Continued) Usual, Customary Schedule of Code Procedure and Reasonable Indemnity Allowance 1 High Medium Low 05640 Replace Broken Tooth on UCR $ 14.00 $ 12.00 $ 9.00 Denture (Removable) - No other Repairs 05650 Adding Tooth to Partial UCR 28.00 23.00 17.00 Denture to Replace Extracted Tooth-Each Tooth (Not involving clasp or abutment tooth) 05660 Adding Tooth to Partial UCR 40.00 32.00 25.00 Denture to Replace Extracted Tooth-Each Tooth (Involving clasp or abutment tooth) 05670 Reattaching Damaged Clasp UCR 24.00 19.00 15.00 on Denture 05680 Replacing Broken Clasp with UCR 34.00 27.00 21.00 New Clasp on Denture 05690 Each Additional Clasp with UCR 28.00 23.00 17.00 Rest (Used in conjunction with code 05680) 06930 Recement Bridge UCR 12.00 10.00 7.00 Benefits are not available for fixed bridge repairs nor recementing of crowns, bridges, or inlays within six (6) months of original placement. The above procedures involving recemen- tations and denture repairs shall be deemed to include all necessary balancing of occlusion, relief of sore spots, and all other adjustments. f. EMERGENCY PALLIATIVE TREATMENT, as follows: 02940 Fillings (Sedative) UCR $ 6.00 $ 5.00 $ 4.00 09110 Palliative (Emergency) Temporary Treatment of Dental Pain UCR 8.00 6.00 5.00 Benefits are not available for permanent restoration nor temporary crowns. Ig. OPERATIVE DENTISTRY fillings consisting of resin, silver amalgam, and tooth color synthetic restorations, as follows: i 02110 Amalgam-One Surface, UCR $ 10.00 $ 8.00 $ 6.00 11 Deciduous (e.g. #K-O-AM) 02120 Amalgam -Two Surfaces, UCR 14.00 12.00 9.00 Deciduous (e.g. #K-MO-AM) 02130 Amalgam-Three Surfaces, UCR 18.00 14.00 11.00 Deciduous (e.g. #K-MOD-AM) `t. Form No. 2807 i I ARTICLE V-DENTAL BENEFITS PROVIDED (Continued) usual, Customary Schedule of Code Procedure and Reasonable Indemnity Allowance High Medium Low 02131 Amalgam- Four Surfaces, UCR $ 20.00 $ 16.00 $ 12.00 Deciduous (e.g.#K-MODL-AM) 02140 Amalgam-One Surface, UCR 12.00 9.00 7.00 Permanent (e.g. #19-0-AM) 02150 Amalgam-Two Surfaces, UCR 17.00 14.00 10.00 Permanent (e.g. #19-MO-AM) 02160 Amalgam-Three Surfaces, UCR 21.00 17.00 13.00 Permanent (e.g.#19-MOD-AM) 02161 Amalgam- Four or More UCR 24.00 19.00 15.00 1 Surfaces, Permanent (e.g. #19-MODBL-AM) -� 02190 Pin Retention-Exclusive of UCR 8.00 7.00 5.00 Amalgam 02210 Silicate Cement-Per UCR 14.00 11.00 6.00 I Restoration (e.g. #8-MIF-Sil) 02310 Acrylic or Plastic UCR 16.00 13.00 10.00 02330 Composite Resin-One UCR 14.00 11.00 8.00 1 Surface (e.g. #24-M-Comp) 02331 Composite Resin-Two UCR 20.00 16.00 12.00 I Surfaces (e.g. #24-ML-Comp) 02332 Composite Resin-Three UCR 28.00 23.00 17.00 Surfaces (e.g.#24-MLD-Comp) 02334 Pin Retention-Exclusive of UCR 8.00 7.00 5.00 Composite Resin or Plastic 02335 Composite Resin- (Involving UCR 27.00 22.00 17.00 Incisal Edge) The above procedures for amalgam, silicate, plastic, and composite restorations shall be deemed to include all necessary bases (except pulp cap), liners, local anesthetics, and postoperative care. Benefits are not available for silicate, acrylic, or composite restoration of class 2 lesions. h. SIMPLE EXTRACTIONS, as follows: I 07110 Single Tooth UCR $ 13.00 $ 10.00 $ 8.00 07120 Each Additional Tooth (In UCR 12.00 10.00 7.00 conjunction with 07110) The above procedures shall be deemed to include postoperative care, local anesthetics, sutures, and suture removal. 6L91 V-000'808Z 809Z 'ON WIOJ 00'L£ 00'617 00'09 uon sdA_L Ieia}el!8 elgenouaa){ SZSLO 00'L£ 00'6t7 00'09 Hurl edAi !eaaw!!un a!genou @H 0Z9[0 ` 00'LZ 00'9£ 00'ti17 kjon adAjL leaalel!8—pax!d S LS LO 00'ZZ $ 00'6Z $ 00,9E $ uon adA_L !eiam!un—pax13 OLSLO :sm011od Se `SH3NId1NIdW 30`ddS 3-19VAON38 HO a3XI3 I •sgluow 9 jo poped e 101 juaw}eaa} aieo aAlJeiado}sod pue -aid pue ;uaw}e I leueo }ooi aAlJoe jo asinoo eqj 6uiinp ua�e; sgdei6oipei }uawleeil lie apnloui of powaap aq llegs sainpeowd anoge eqj l (syluow 8 L of 9 jo poiiad a JOAO pualxa 00'0b 00'ZS 00'tb9 uon Am ;uawleeil) uoi;eoij!xady 05££0 { (leueo loos palIg alsed) 00'09 00'8L 00'96 uon 6uill!d leue0 looH ieloW L£££0 (uopeiolsai leuil sapn!oxe) 00'96 00'£ZL 00'Z9L uon 6uill!d leue0 loon ielo" 0£££0 (leueo loos pall!] alsed) 00'09 00'99 00'08 uon 6uill!d leue0 loon p!dsnoi8 L3££0 (uo!leiolsai leuil sapnloxa) 00'9L 00'L6 00'0ZL uon 6uill!d leue0 looH p!dsnoi8 OZ££0 (leueo loos pal!!j alsed) 00'017 00'ZS 00'179 uon 6uill!d leue0 looH ioiialuy L L££0 (uoileiolsai leuil sapnloxa) 00'Z9 00'L8 00*00L Lion 6uill!d leue0 loolJ iolialuy 01££0 (dlnd Ie;!A pasodxa ue}o uo!liod leuoioo ay}jo { lenowai ayl) uo!jeioIsaa leUlZi L 00'6 00'Z L 00'171 Bon sapnl3x3—Awolodind Ie1IA OZZ£0 (uiluep Aiepuooas jo uoijewiol ayi alelnwils of pue saouanljui Ieuia}xa woij 3! ;oaloid of dlnd pasodxa ayl of ` 6nip e;o uopeoildde ayl) L uoijeiolsed leUid sapnlox3 00'9 $ 00'8 $ 00'0L $ uon —;oaila—de0 dlnd OLL£0 :sanoliOI se `1N3W1H3al OUNOOOGN3 '! MO-1 wnlpaw 461H eouemollb Al!uwapul elgeuoseaa pue einpaooad ap00 ;o alnpayoS Ajewol;sn0 °Iensn (penuiluo0) a3alA0ad S1IA3N38 IVIN30—A 3-IOIIUV { ARTICLE V—DENTAL BENEFITS PROVIDED (Continued) Usual, Customary Schedule of Code Procedure and Reasonable Indemnity Allowance High Medium Low 01550 Recementation of Space UCR $ 8.00 $ 6.00 $ 5.00 Maintainer (Available only after six (6) months have elapsed from the date of placement of the maintainer) Benefits for the above procedures are not available unless such procedures are necessary to prevent future orthodontic care or complications. Benefits are not available after completion of orthodontic treatment or for modification of an existing space maintainer unless such modification is required because of the related change in the condition of the oral cavity. k. TESTS AND LABORATORY EXAMS, as follows: 00460 Pulp Vitality Tests—Each UCR $ 5.00 $ 4.00 $ 3.00 visit (One visit in any twelve-month period) t 00470 Diagnostic Casts UCR 8.00 6.00 5.00 tt 07285 Biopsy of Oral Tissue (Hard) UCR 28.00 23.00 17.00 t (Report Required) t( 07286 Biopsy of Oral Tissue (Soft) UCR 20.00 16.00 12.00 (Report Required) I. OTHER BASIC SERVICES, as follows: 09220 General Anesthesia UCR 26.00 21.00 16.00 09410 House Calls UCR 13.00 10.00 8.00 09420 Hospital Calls (Does not UCR 10.00 8.00 6.00 include postoperative visits, special consultation or visits for a noncovered service) ` 2. ADDITIONAL BASIC BENEFITS If item 6 of the Schedule is indicated "Applied For," the following Covered Dental Expenses will be paid up to the Dentist's charge, not to exceed: (a) If item 7 of the Schedule is indi- cated, the percentage of the Dentist's Usual, Customary and Reasonable charge (UCR) as indicated in item 8 of the Schedule, or (b) If item 9 of the Schedule is indicated, the indemnity allowance of either High, Medium, or Low as indicated in item 10 of the Schedule. - a. ORAL SURGERY consisting of diagnosis and treatment, as follows: 07210 Extraction of Tooth—Erupted UCR $ 20.00 $ 16.00 $ 12.00 _ (Due to root configuration or other condition, surgical �- intervention is required) i i ARTICLE V— DENTAL BENEFITS PROVIDED (Continued) Usual, Customary Schedule of Code Procedure and Reasonable Indemnity Allowance High Medium Low 07220 Extraction of Tooth—Soft UCR $ 29.00 $ 23.00 $ 18.00 Tissue Impaction (Tooth Crown is encased in soft tissue) 07230 Extraction of Tooth—Partial UCR 32.00 26.00 20.00 Bony Impaction (Tooth Crown is partially encased in bone, part in soft tissue) 07240 Extraction of Tooth— UCR 60.00 49.00 37.00 Complete Bony Impaction (Tooth is completely encased in bone) 07241 Extraction of Tooth— UCR 72.00 58.00 45.00 I Complete Bony Impaction (Tooth is completely encased in bone and presents unusual -� difficulties and circumstances) 07250 Root Recovery—Surgical UCR 40.00 32.00 25.00 Removal of Residual Root (A retained root from previous extraction or retained from fractured tooth) 07260 Oral Antral Fistula Closure UCR 72.00 58.00 45.00 and/or Antral Root Recovery (Removal of a root or root tip and/or the closing of a hole in the maxillary sinus cavity) 07270 Tooth Replantation UCR 100.00 81.00 62.00 07280 Surgical Exposure of Impacted UCR 28.00 23.00 17.00 or Unerupted Tooth for Orthodontic Reasons— including wire attachment when indicated (Causing a tooth to erupt by removal of bone and tissue) 07281 Surgical Exposure of UCR 19.00 16.00 12.00 Impacted or Unerupted Tooth to aid eruption 07310 Alveoplasty, per Quadrant— UCR 61.00 49.00 38.00 In conjunction with extractions t (Sometimes referred to as JAlveolectomy) (Surgical preparation of ridge for Jreceipt of dentures) F .m N ono (4laal waoj ! dlay leyl sonssll ao ulool e wool 6ulleul6lao sonssll of saalai oluaboluopp) aalawelp ul Uoul lle4-auo of do —(wseldoaN) aownl jo lsAo 00'0£ 00,6E 00'817 uon olua6oluopp jo lenowaH 09t,L0 youl lle4-auo aano aa}awelp uolsa-j— 00'SL 0016 00'03L uon aownl lueu6lle" to uolsl0x3 LbtiLO (aownl snoaaoueo to lenowaa leol6anS) youl l!eu-auo of do aalawelp uolse-1— 00'L£ 00'6b 00'09 uon jownl lueu6!leW 10 uolslox3 Ot t7L0 pul lley-auo aano aalawela uolsal 00'39 00'L8 00'00 L uon —aownl u6lu98 10 uolsl0x3 LEti10 (gown; snoiaoueouou to lenow91 leol6anS) youl lley-auo of do aalawelo uolsa-I 00'0£ 00'6E 00'8b uon —aownl u61ua8 to uols!0x3 OEtLO 00'8 00'0L 00'EL aofl en16ulE) leuoaoolaad uolsl0x3 93VLO yowl dle4-auo aano aalawela 00'09 00'8L 00'96 uon uolsa-j—uolslox3 leo!Ped O3tiL0 (suolsal ao anssll aeos to lenowaa leol6anS) youl lle4-auo of do aalawela 00,0E 00,6E 00'817 boll uolsa-l—uolslox3leolPea OLVLO anssll ollseldiadAq pue palydoala9dAL4 ;o luewe6euew pue 'sljea6 anssll llos `uolsuaixe a6pla 6ulpnioul—paleolldwoo 00'06 00'LLL 00'17bL doll —yojv aad 'AlseldolewolS 09EL0 (sainluep jo idlaoaa aol Allensn 'ylnow ayl to Aia6ans ollseld jo uollonilsuooeH) paleolldwooun 00'6L 00'93 00,0E uon —coat/ jad 'AiseldolewolS OVELO (sainluep jo ldlaow aol a6pp jo uolleaedaid leol6anS) suoll3eJlx3 qpm uollounluoo ul ION 00,8E $ 00'617 $ 00'L9 $ aofl —lueapenD aad 'Alseldoanly OZELO nno-1 wnipaw 461H eauemolid AIiuwapuI algeuoseaa pue einpaooJd ap03 jo ainpagoS fiewolsno llensn (panuliuoO) a3alAOad S11:13N38 1d1N3a—A 3'l01lad ARTICLE V-DENTAL BENEFITS PROVIDED (Continued) Usual, Customary Schedule of Code Procedure and Reasonable Indemnity Allowance High Medium Low 07451 Removal of Odontogentic Cyst UCR $100.00 $ 81.00 $ 62.00 or Tumor-over one-half 1 inch in diameter 07460 Removal of Non-Odontogentic UCR 48.00 39.00 30.00 Cyst or Tumor-up to one-half inch in diameter 07461 Removal of Non-Odontogentic UCR 100.00 81.00 62.00 1 Cyst or Tumor-over one-half inch in diameter 07470 Removal of Exostosis- UCR 44.00 36.00 27.00 Mandible or Maxilla (Surgical removal of a spur or bony outgrowth from a bone or the root of a tooth) 07480 Partial Ostectomy-Guttering UCR 44.00 36.00 27.00 or Saucerization (Surgical _ removal of bone resulting in a gutter-like or saucer-like depression) 07490 Radical Resection of Mandible UCR 320.00 260.00 200.00 with Bone Graft(Removal of part of the lower jaw with a bone graft replacement) 07510 Incision and Drainage of UCR 13.00 10.00 8.00 Abscess, Intraoral (Cutting or j lancing of an abscess inside the mouth, to provide drainage) 07520 Incision and Drainage of UCR 24.00 19.00 15.00 Abscess-Extraoral (Extraoral -outside the i mouth) 07530 Removal of Foreign Body UCR 20.00 16.00 12.00 (Excludes Bone Spicule) 07540 Removal of Reaction- UCR 28.00 23.00 17.00 Producing Foreign Bodies- Musculoskeletal System 07550 Sequestrectomy for UCR 52.00 42.00 32.00 Osteomyelitis (The surgical removal of a fragment of dead bone) Laboratory report required. i ARTICLE V-DENTAL BENEFITS PROVIDED (Continued) Usual, Customary Schedule of Indemnity Allowance Code Procedure and Reasonable 1 High Medium Low 07720 Fractured Maxilla- UCR $228.00 $185.00 $142.00 Compound-Closed Reduction (See description code 07620) 07730 Fractured Mandible-Open UCR 228.00 185.00 142.00 Reduction of Compound Fracture -� 07740 Fractured Mandible-Closed UCR 228.00 185.00 142.00 Reduction of Compound Fracture 07750 Fractured Malar and/or UCR 240.00 195.00 150.00 Zygomatic Arch-Compound -Open Reduction 07760 Fractured Malar and/or UCR 180.00 146.00 112.00 Zygomatic Arch-Compound -Closed Reduction 07770 Fractured Alveolus- UCR 180.00 146.00 112.00 Compound-Stabilization of Teeth-Open Reduction 1 -Splinting 1 07780 Facial Bones-Complicated UCR 360.00 292.00 225.00 i Reduction with Fixation and )I Multiple Surgical Approaches 07810 Open Reduction of Dislocation UCR 56.00 45.00 35.00 of the Mandible (Surgical incision required for access to the Temporomandibular Joint) 07820 Closed Reduction of UCR 20.00 16.00 12.00 Dislocation of the Mandible (Manipulation to position the mandible in its normal position) 07830 Manipulation Under UCR 40.00 32.00 25.00 Anesthesia 07840 Condylectomy (Removal of UCR 280.00 227.00 175.00 1 one of the condyles of the mandible) 07850 Meniscectomy (Removal of UCR 240.00 195.00 150.00 the disc between the head of the condyle and the base of the temporal bone) _1 J ARTICLE V—DENTAL BENEFITS PROVIDED (Continued) I Usual, Customary Schedule of Code Procedure and Reasonable Indemnity Allowance High Medium Low 07560 Maxillary Sinusotomy for UCR $ 72.00 $ 58.00 $ 45.00 removal of tooth fragment or foreign body 07610 Fractured Maxilla—Simple UCR 280.00 227.00 175.00 —Open Reduction—Teeth Immobilized (if present) (Open reduction requires cutting to expose fractured sight) -� 07620 Fractured Maxilla—Simple UCR 200.00 162.00 125.00 —Closed Reduction— Teeth Immobilized (if present) (Closed reduction is a manipulative reduction without incision) 07630 Fractured Mandible—Simple UCR 280.00 227.00 175.00 —Teeth Immobilized — Open Reduction (See description 07610) 07640 Fractured Mandible—Simple UCR 220.00 179.00 137.00 —Teeth Immobilized — ! Closed Reduction ! (See description 07620) 07650 Fractured Malar and/or UCR 220.00 179.00 137.00 Zygomatic Arch—Simple— Open Reduction (Cheek bone region) 07660 Fractured Malar and/or UCR 80.00 65.00 50.00 Zygomatic Arch—Simple— Closed Reduction 07670 Fractured Alveolus—Simple UCR 80.00 65.00 50.00 —Stabilization of Teeth— Open Reduction—Splinting (A fracture of the bony process surrounding the teeth) 07680 Fractured Facial Bones— UCR 320.00 260.00 200.00 Complicated Reduction with Fixation and Multiple Surgical Approaches #` 07710 Fractured Maxilla— UCR 300.00 244.00 187.00 Compound—Open Reduction (See description code 07610) 6L91 V-000'Z l9Z ZL9Z 'ON WJOJ 1 'alnpayoS ayj ;o gl wall ul paleo!pui se mo-I ao `wn!pan `01H aayl!a 10 aouemolle Al!uwapul ayl `pa;eo!pui si alnpayoS ayj jo til wall 11 (q) Ao `alnpayoS ay} ;o £1 wai! ul pajeolpu! 1 se Won) a6aeyo algeuosea» pue Ajewolsno `lens s,Islluaa 941 10 abeluaoaad ayj `pal.eo 1 -!pui si alnpayoS ayt jo Z1 wall 11 (e) :paaoxa 01 IOU a5aeyo s,ls!tuaa ayj of do pled aq 11!M sasuadx3 leluaa paaanoO 6u!nn01101 ay> „`Jo3 pa!iddy„ palempul sl alnpayoS ayj jo L1 wall 1.1 f S11d3N38 OU3H1SOad 'E 1 (uoiliod umoao pal.elaa s}! pue yl001 paIooa-!llnw a to Iooi e 00'9Z 00'Z£ 00'017 doll 10 lenowaa ayi) uolIoaslwaH OZ6£O :sMOIIOJ se `3un(13008d OUNOaOON3 0 (saanpaooad Ieo!6ans 6u!pnloui looi a }o xade ay} 00,0E 00'6£ 00'8t, don 10 6u!II!3) 6u!II!d apea6oa;a8 0£17£0 uoljelndluew oliuopopu3 yt!m uo!tounluoO 00'9ti 00'89 00'ZL don ul pawao;aad—Awo3oaooldy OZV£0 (ytoot a 10}ooa ay}to xade t ay;jo uogetndwy) aanpaooad leol6anS ateaedaS e f 00'0£ $ 00'6£ $ 00'817 $ boll se pawaotjad—Awoloaoo!dy 0 Lt7£0 :smO1101 se `S301A83S IVOldVIH3d q •sanssli ;tos lean a9410 pue aleled `en6uol `;uawyoelleaa alosnw 'sa6pp ay} }o anss!I.ttos aya.}o uolslnaa apnlou! 11eys Alseldolewots aol st!tauaq :suo!toeatxe apnloul;ou Ileys Ajseldoanle JOI st!laueq :sol1ayl.saue leooi pue lenowaa ailm pie ao/pue aanlns `saanins `aaeo anlleaadolsod pue anlleaadoaad augnoi apnloui lleys saanpaooad leol6ans Ieao dot stltaua8 00'017 00'Z9 00119 don Awoloayoeal Aoua6a9w3 066LO l (tonp Ajenlles ay;sanlonul yolynn abessed lewaouge ue jo 6ulsolo) 00'Zb 00'99 00'89 doll elnts!3 AjenlleS to ainsolo £86LO (lonp Aaenlles ayl uo uo!jeaado 00'09 00'99 00'08 doll o!tseld y) Alseldoyoopole!S Z86LO 00'09 00'8L 00'96 boll puelO AaenlleS 10 u01S10X3 186LO I (snlnoleo e L 10 Ienowaa ayj aol jonp ao puel6 plloaed ayt to uo!s!oul) 00'Zt, 00'99 00'89 don (p!l0aed) Awoloyt!lole1S 086LO (41MOJ6 anlssaoxa of anp ao saanluap to id!aoaa aol AIlensn `anss!I an!ssaoxa 10 L Ienowad) yoay dad —anss!1 00'0Z $ 00'9Z $ 00'Z£ $ !doll oltseldiadAH 10 uolslox3 OL6LO f Iwo, wnlpaW 461H L aouemolld AI!uwapul algeuoseaa pue aanpaooad apoO l,o alnpayoS Ajewol;snO 'lens (panui;uoo) a3aIAOad S11d3N38 1d1N3a—A 31311MV ARTICLE V-DENTAL BENEFITS PROVIDED (Continued) Usual, Customary Schedule of f Code Procedure and Reasonable Indemnity Allowance High Medium Low 07860 Arthrotomy (The surgical UCR $ 48.00 $ 39.00 $ 30.00 incision of a joint) 07870 Arthrocentesis (The UCR 24.00 19.00 15.00 puncturing and aspirating of a joint) 07910 Simple Suture of Recent UCR 20.00 16.00 12.00 Small Wounds-Up to two inches in diameter 07911 Complicated Suturing of UCR 48.00 39.00 30.00 Wound - Reconstruction requiring delicate handling of tissues-Wide undermining for meticulous closure- up to t,Ao inches in diameter 07912 Complicated Suturing of UCR 64.00 52.00 40.00 Wound- Reconstruction requiring delicate handling tl of tissues-Wide undermining for meticulous closure-diameter over two inches 07920 Skin Grafts (Wounds) - UCR 150.00 12.00 90.00 Identify Defect Covered- Location and Type of Graft - Donor Site 07930 Injection of Trigeminal Nerve UCR 40.00 32.00 25.00 I for Destruction (An injection in the area of the nerve which acts to destroy it) 07931 Avulsion of Trigeminal Nerve UCR 100.00 81.00 62.00 (The removal of the nerve) 07940 Osteoplasty-For UCR 40.00 32.00 25.00 L Orthognathic Deformities 07950 Osteoperiosteal, Periosteal or UCR 350.00 280.00 210.00 Cartilage Graft of the Mandible 07955 Repair of Maxillofacial Soft UCR 100.00 80.00 60.00 t and Hard Tissue Defects L 07960 Frenulectomy-Separate UCR 64.00 52.00 40.00 Procedure (Frenectomy or Frenotomy) ARTICLE V- DENTAL BENEFITS PROVIDED (Continued) Usual, Customary Schedule of Code Procedure and Reasonable Indemnity Allowance High Medium Low 05250 Upper-with gold palatal bar UCR $280.00 $227.00 $175.00 1 and two clasps, acrylic base 05251 Upper-with chrome palatal UCR 280.00 227.00 175.00 bar and two clasps, acrylic base 05260 Upper-with gold palatal UCR 240.00 195.00 150.00 bar and two clasps, cast base 1 05261 Upper-with chrome palatal UCR 240.00 195.00 150.00 bar and two clasps, cast base 05280 Removable unilateral partial UCR 100.00 81.00 62.00 denture one-piece gold casting, clasp attachments, per unit including pontics 05281 Removable unilateral partial UCR 100.00 81.00 62.00 denture one-piece chrome casting, clasp attachments, per unit including pontics 05291 Full-cast partial -with two UCR 240.00 195.00 150.00 gold clasps (upper) 05292 Full-cast partial -with two UCR 240.00 195.00 150.00 chrome clasps (upper) 05293 Full-cast partial-with two UCR 240.00 195.00 150.00 gold clasps (lower) 05294 Full-cast partial -with two UCR 240.00 195.00 150.00 1 chrome clasps (lower) l 05310 Each additional clasp with UCR 20.00 16.00 12.00 rest (added at time of construction of dentures) 05320 Each tooth (applies to codes UCR 10.00 8.00 6.00 05291 and 05294 only) 05830 Obturator-for surgically UCR 144.00 117.00 90.00 excised palatal tissue I (a prosthesis used to close an opening in the palate) 05840 Obturator-for deficient UCR 200.00 162.00 125.00 J velopharyngeal function (cleft palate) The above procedures shall include base adjustments, clasp and rest adjustments, framework adjustments, relief of sore spots, rebalancing occlusion, and six (6) months post-delivery care. J J Fnrm Nn 9A1'i - ,,__ -- ___ aseq lseo 'sdselo onnl pue aeq 00'09L 00'96L 00'017Z uon Ienbull awoago ql!m—Aa.mo-I LbZ90 aseq lseo 'sdselo onnl pue 1 00'09L 00'96L 00'Ot7Z uon aeq Ienbull plot ql!m—aanno-1 OtbZ90 (slepalew liegoo-awoago of saa}aa ainlelauawou eql ul 1 pasn „awoago„ weal aql) aseq ollAjoe 'sdselo onnl pue aeq 00'Z9 L 00'L LZ 00'09Z uon Ienbull awoago gllnn—aanno� L£Z90 1 aseq ollAjoe 'sdselo onnl pue 0079 L 00'L lZ 00'09Z uon jeq Ienbull plot glln^—aanno-1 0£ZSO aseq ollAjoe 'sisaa gllnn sdselo 00'09l 00'96L 00'O17Z a:Dn awoago onnl gllnn—aanno-1 9L390 aseq oilAjoe 'slsai 4lIM 00'09L 00.961 00'OtiZ uon sdselo p106 onnl gllnn—aanno-1 LLZ90 aseq ollAjoe 'slsai gllnn sdselo 00'09L 00'96L 00'O17Z uon awoago onnl q;inn—aaddn 9LZS0 aseq oilAjoe `sisal 4lln^ 00'09L 00'96L 00'O17Z uon sdselo plot onnl gllnn—aaddn gLz90 aseq ollAjoe 00.9L 00'L6 00.0Z L uon 'sdselo lnogliM—aanno-i Z LZg0 (jaddlll a se of paaaal.ai Alluenbail) aseq ollAjoe 1 00'9L 00'L6 00'OZL uon `sdselo lnogllnn—jaddn L LZ90 S3uniN3a -ldlidVd •aaeo AnAllap-;sod sgluow (9) xis pue 'uolsnl000 6ulouelegaa 'slods aaos l.o lanai 'sluawlsnlpe aseq apnloul Ilegs sainpaooad anoge aql (aaddn alelpawwl aol uolldlaosep 00'L£L 00'6LL 00'OZZ uon aag) aanno-1 alelpawwl Oblg0 { (glaal bululewai aql Ile 10 Ienowaa aql 6ulnnoIIOI Alelelpawwl palaasul sl legl auo sl ainluep alelpawwl 001£L 00'6LL 00'OZZ uon uy) aaddn alelpawwl O£LSO 00'9Zl 00'Z91 00'003 ljon aanno-i alaldwoo OZLSO i 00'9Zl$ 00•Z9L$ 00'003 uon jaddn aloldwoo OLLSO j S38n1N3Q -nnd :snnollol se 'IVIiHVd (INV -lln3 '63un1NM e nno� wnlpalM 461H eouemolld Alluwapul elgeuoseaa pue aanpaooad opoo jo alnpo4oS Aiewolsno `lens (penunuoO) a3alA0ad S11:13N38 IVIN3a — A 31311UV ARTICLE V- DENTAL BENEFITS PROVIDED (Continued) Usual, Customary Schedule of Code Procedure and Reasonable Indemnity Allowance High Medium Low b. DENTURE ADJUSTMENTS AND RELINING are those procedures required to attain a satisfactory prosthetic appliance, as follows: 05410 Complete Denture UCR $ 11.00 $ 9.00 $ 7.00 (Adjustment) 05421 Partial Denture (Upper) UCR 11.00 9.00 7.00 (Adjustment) I 05422 Partial Denture (Lower) UCR 11.00 9.00 7.00 (Adjustment) 05730 Relining upper or lower UCR 40.00 32.00 25.00 complete denture (office reline) 05740 Relining upper or lower UCR 52.00 42.00 32.00 t partial denture (office reline) 05750 Relining upper or lower UCR 64.00 52.00 40.00 complete denture (laboratory) 05760 Relining upper or lower UCR 60.00 49.00 37.00 partial denture (laboratory) Benefits for the above procedures are not payable within the first six (6) months following the initial installation of the appliance. Denture adjustments are limited to three (3) adjust- ments in any one consecutive twelve (12) months period and are limited to dentists other than the one who provided or repaired the initial appliance. The above procedures include base adjustments, clasp and rest adjustments, framework adjustments, relief of sore spots, and base occlusions. c. BRIDGES, fixed and removable (Each pontic [false or replacement tooth] and each abut- ` ment [crown or inlay] is referred to as a unit [e.g., a six-unit bridge could be #6 crown, #7, 8, 9, 10-pontics, #11 crown]), as follows: 06210 Cast gold pontics UCR $120.00 $ 97.00 $ 75.00 06211 Cast non-precious pontics UCR 80.00 65.00 50.00 L 06212 Cast semiprecious pontics UCR 96.00 78.00 60.00 06220 Slotted facing pontics UCR 96.00 78.00 60.00 06230 Slotted pontic UCR 100.00 81.00 62.00 06240 Porcelain fused to gold pontic UCR 160.00 130.00 100.00 06241 Porcelain fused to UCR 136.00 110.00 85.00 non-precious metal pontic 06242 Porcelain fused to UCR 144.00 117.00 90.00 semiprecious metal pontic 06250 Plastic processed to UCR 120.00 97.00 75.00 L gold pontic f ARTICLE V- DENTAL BENEFITS PROVIDED (Continued) Usual, Customary Schedule of Code Procedure and Reasonable Indemnity Allowance High Medium Low 06251 Plastic processed to UCR $109.00 $ 88.00 $ 68.00 non-precious metal pontic 06252 Plastic processed to UCR 112.00 91.00 70.00 semiprecious metal pontic 06520 Gold inlay-two surfaces UCR 104.00 87.00 65.00 (retainer part of bridge) 06530 Gold inlay-three or more UCR 112.00 91.00 70.00 surfaces (retainer part of bridge) 06540 Gold inlay-(Onlaying cusps) UCR 12.00 10.00 7.00 (Retainer part of bridge) 06710 Plastic (acrylic) crowns UCR 80.00 65.00 50.00 06720 Plastic processed to gold UCR 116.00 94.00 72.00 crowns 06721 Plastic processed to UCR 109.00 88.00 68.00 non-precious metal crown 06722 Plastic processed to UCR 112.00 91.00 70.00 semiprecious metal crown ( 06740 Porcelain Crown UCR 120.00 97.00 75.00 l 06750 Porcelain fused to gold crown UCR 160.00 130.00 100.00 06751 Porcelain fused to UCR 136.00 110.00 85.00 non-precious metal crown 06752 Porcelain fused to UCR 144.00 117.00 90.00 semiprecious metal crown �._ 06780 Gold (3/4 cast) crown UCR 108.00 88.00 67.00 06790 Gold (full cast) crown UCR 120.00 97.00 75.00 L_ 06791 Non-precious metal (full cast) UCR 83.00 68.00 52.00 06792 Semiprecious metal (full cast) UCR 80.00 78.00 60.00 06960 Dowel pin-metal UCR 19.00 16.00 12.00 L d. FIXED PROSTHODONTIC REPAIRS-Procedure performed on a nonremovable bridge Lto restore it to its previous functional state, as follows: 06610 Replace broken pin facing UCR $ 18.00 $ 15.00 $ 11.00 with slotted or other facing L06620 Replace broken facing where UCR 16.00 13.00 10.00 post is intact L 06630 Replace broken facing where UCR 24.00 19.00 15.00 post backing is broken L Form No. 2914 2814.000-AL679 ARTICLE V— DENTAL BENEFITS PROVIDED (Continued) Usual, Customary Schedule of Code Procedure and Reasonable Indemnity Allowance r High Medium Low [I 06640 Replace broken facing UCR $ 48.00 $ 39.00 $ 30.00 with acrylic 06650 Replace broken pontic UCR 18.00 15.00 11.00 The above procedures include relief of sore spots and rebalancing of occlusion. 4. PERIODONTIC BENEFITS If item 16 of the Schedule is indicated "Applied For," the following Covered Dental Expenses will be paid up to the Dentist's charge, not to exceed: (a) If item 17 of the Schedule is indi- cated, the percentage of the Dentist's Usual, Customary and Reasonable charge (UCR) as indicated in item 18 of the Schedule, or (b) If item 19 of the Schedule is indicated, the indemnity allowance of either High, Medium, or Low as indicated in item 20 of the Schedule. Periodontal procedures shall consist of: Surgical periodontic examination; Gingival Curet- tage; Gingivectomy and Gingivoplasty; Osseous Surgery, including flap entry and closure; Mucogingivoplastic surgery; Management of acute infection and oral lesions, as follows: 04210 Gingivectomy or Gingivoplasty UCR $ 48.00 $ 39.00 $ 30.00 —Per Quadrant (Gingivectomy is the removal of the gingival tissue from about the necks of the teeth thus eliminating subgingival i pockets.) (Gingivoplasty is defined as the recontouring of the gingival tissue.) 04220 Gingival Curettage and root UCR 24.00 20.00 15.00 planing (removal of diseased tissue and smoothing of root surface—Per quadrant) 04240 Gingival Flap Procedure (Per UCR 64.00 52.00 40.00 Quadrant) (A procedure in which the bone is recontoured and the gingival tissue is reattached at a lower site on the neck of the tooth.) 04250 Muco-Gingival Surgery per UCR 56.00 45.00 35.00 L Quadrant 04260 Osseous Surgery (Including UCR 60.00 49.00 37.00 flap entry and closure)per quadrant (Surgery performed on the alveolar bone) 6/9-IV--O00'SlBZ Sl9Z 'oN wioj I quawleeil to asinoo awes a4l 6uianp lueipenb awes a4l uo pewioliad uagm 'Aiabins snoasso—093t0 pue 'einpaooid dell len16ui6—017Z170 sainp000id iol elgeliene lou aie slilau98 •31194lsaue 1e001 pue 'lenowai pue luawaoeld Noed leluopoped 'Ienowaa ainlns 'sainlns 'aieo anileiadolsod pue aid ouilnoi apnioui sainpaooid leluopoliad anoge a41 (41981 ZL Ue4l 00'6 007L 00'17l »on iannad) bulleoS lelu0poliad 117SVO (snlnoleo c leni6uibgns to lenowai 841 iol„6uileos deep„ y) 4lnow 00's1. 00'61. 0011Z uon aillu3-6uileoS 1elu0po1i8d 0176V0 �- 00'str 00*89 007L doll AlseldoingilsOA ZLZb0 (paq sli woil paail Alalaidwoo anssil to lleib y) (ells iouop 6uipnloul) 00'09 00'99 00'09 boll sllei!D anssil llos aaid LM,0 ('ells iouop 941 of pa4oelle sulewai I 4o1gm lied a)iil-loot a Aq pa4oelle anssil snoeuelnogns a4l pue uiNs a41 to ssauNol4l lint a4l 10 6ullsisuoo lleib y) 007£ 00'Ztl 0079 eon slleio anssil lloS alaipad OM70 (alis iouop pue ainsolo pue Ailue dell 6uipnloul) sells 00'L9 00'88 00'80L uon aldillnw—slleio snoasso Z9Zb0 (•loelap Auoq e iledai of io auoq panowai a to eoeld a4l a�el of pasn pue luailed eql to auoq ia4lo awos woil ua>{el auoq to ooeid y) (alis iouop pue ainsolo pue Ailua dell 6uipnloul) 00'LE $ 00'6117 $ 00'09 $ uon ails al6uls—slleio snoasso L9Ztb0 mo-1 wmpoW 461H eouemoliv Alluwepul elgeuoseaa pue ainpaooJd ap03 jo alnpegoS Ajewolsno `lens (penunuoW a3a1A0ad S11d3N3S 1d1N3a —A 31011HV ARTICLE V— DENTAL BENEFITS PROVIDED (Continued) Usual, Customary Schedule of Code Procedure and Reasonable Indemnity Allowance High Medium Low 04261 Osseous Grafts—single site UCR $ 60.00 $ 49.00 $ 37.00 (Including flap entry and closure and donor site) (A piece of bone taken from some other bone of the patient and used to take the place of a removed bone or to repair a bony defect.) 04262 Osseous Grafts—multiple UCR 108.00 88.00 67.00 sites (Including flap entry and closure and donor site) 04270 Pedicle Soft Tissue Grafts UCR 52.00 42.00 32.00 (A graft consisting of the full thickness of the skin and the subcutaneous tissue attached by a foot-like part which remains attached to the donor site.) 04271 Free Soft Tissue Grafts UCR 80.00 65.00 50.00 (Including donor site) (A graft of tissue completely freed from its bed) 04272 Vestibuloplasty UCR 72.00 58.00 45.00 04340 Periodontal Scaling—Entire UCR 24.00 19.00 15.00 mouth (A "deep scaling" for the removal of subgingival calculus) 04341 Periodontal Scaling (Fewer UCR 14.00 12.00 9.00 than 12 teeth) The above Periodontal Procedures include routine pre and postoperative care, sutures, suture removal, periodontal pack placement and removal, and local anesthetic. Benefits are not available for procedures 04240—gingival flap procedure, and 04260—osseous surgery, Lwhen performed on the same quadrant during the same Course of Treatment. L I Form No. 2815 2815.000-AL679 oes-1v—000'auaz t'gLSZ 'oN wJOA •buluoilisodai r aalle glaa; ay; 10 uoilualai luenbesgns pue 10 ;uawanow ay; ao1 aouelldde oiluopoyla0 I ue 10 ;uawooeld ay; aainbei 4oi4M pue play oilu0p041a0 ay; ul4l!m ilel of paiapls -uoo Allensn pue Ailewaou sasuadx3 le;uaQ paJanoo asoyl sueew asuadx3 3111-1013000 'p •Al! i 15i a joeiluoo Buijnp juawleeil jo uoilenui;uoo jo looid buimollol saseq Alialienb e uo pled aq of sa6jeyo luawlsnfpe Ile sapnloui yolgM luawleaa; anllod (Z) 1.111auaq wnwlxew awllalll oiluopoy1a0 ay; to %09 paeoxe ;0u lleys luawAed yons pue 'aouelldde 0lluopoyla0 ay; 10 ;uawooeid ay; buipnloui pue of aoud pewaoljad saolnJas Ile 10 ;SIs C -uoo II!m goigm ';uawked leiliui ayl (I,) :sadAj oml 10 aq Ilim sluawAed lllauaq olluop0y;a0 •0 .alnpayoS ayt 10 8Z wall ui paleo -Ipui ley; aq Ileys awilalii sly 6ulanp ;uedl011aed Aue aol aiquAed lilauaq wnwlxew ayl -q •swnwlxew algeoildde ay;of do alnpayoS 941 10 LZ wall ul paleoipui a6elueoiad ay; Aq sasuadx3 oiluopoylj0 yons aol ojon) abieyo algeuosead pue Ajewolsno 'junsn au; 6uiAldilinw Aq paulwaalep ;unowe ue Aud IIIM jalaaeo ay; 'sasu9dx3 oiluopoylj0 inoui ileys aapunaaay p8J9no0 al!gm pue 96e 10 saeaA 6L aapun l eliynn ';uedl011aed nue U84M 'ulaaay 41aol las se swla; aaylo Ile pue suolleliwll 'suols -nioxe 'swnwlxew ayl of loefgns „'jod paiiddy„ paleoipui si alnpayoS ayl 10 9Z wall 11 .e Sild3N38 3I1NOQOHM0 '9 l 'aJeo anileaadolsod pue 'soilaylsaue pool 'saauil 'sdnpllnq '(deo dind ldaoxa) saseq Aiesseoeu Ile apnloui o; pawaap aq Heys sAvluo pue sAelui aol sampeooid anoge ayl 00'8Z 00*9£ 00'9V doll ulelaoa0d —Aelul OL9ZO ylOOl a 10 eoelins 6uipuij6 ao buillq ay;JOAO s;11 yo!gm Aelui ue si Auluo (anoge of uoi}ippe 00'L 00'0L 0071 boll ul) ylool dad—Aelu0 0V9ZO 00'OL 00'L6 00'ZLL soft saoupns eaayl—plot Aelul 0£930 00*99 00,178 00*v01 sort saoelins oMl—p100 Aulul 0Z9Z0 00*99 $ 00'LL $ 00*99 $ dolt aoelans auo— pio0 Aelul OL9ZO l_ MO-1 wnlpeW 46IH eouemolld Alluwapul elgeuoseaa pue einpaooJd epo0 jo alnpayoS Ajewolsn0 'lens _ :smollol se'aoeld olui paluawao uayl si yolynn AllAeo ytool a lit of pawjol uoileaolsai y—(abpijq a 10 lied lou) SATIN q f (uol; -eaglllnbe 1•6•9) a eo anileaado;sod paiinbai pue 'soilaylsaue leooi 'saauii 'sdnpllnq '(6uiddeo dind 6uipnloxe) saseq Ajussaoau Ile apnloui of pawaap aq ileys sainp000id anoge ayl -paJanoo lou aae sumoao Ajejodwal jo leuoillsueal 'lepalew 6ulllll (penuiluoa) a3alAObd SIUM38 'Id1N3a —A 3-10Mb ARTICLE V - DENTAL BENEFITS PROVIDED (Continued) Section B INCENTIVE-USUAL, CUSTOMARY AND REASONABLE CHARGE Subject to the maximums, deductibles, exclusions, limitations and all other terms and provisions set forth herein, when any Participant while covered hereunder shall receive any of the services of a Dentist for which benefits are paid under Section A, Subsections 1, 2, 3, 4, or 5, of this Article V, if item 29 of the Schedule is indicated "Applied For,"the Carrier will provide additional benefits for Covered Dental Expenses incurred during successive Contract Years, commencing with the second of such successive Contract Years,as detailed below. 1. For the second successive Contract Year, the Carrier will provide benefits in the amount of the percentage specified in item 30 of the Schedule, to be applied to the Covered Dental Expenses for which benefits are payable under the preceding Section A, Subsections I 1, 2, 3, 4, or 5, provided payment was made in such Section A, Subsections 1, 2, 3, 4, or 5, for the first Contract Year. 2. For the third successive Contract Year,the Carrier will provide benefits in the amount of the t percentage specified in item 31 of the Schedule, to be applied to the Covered Dental Ex- penses for which benefits are payable under the preceding Section A, Subsections 1, 2, 3, 4, or 5 , provided payment was made under item 1, above, for the second successive Contract Year. 3. For the fourth successive Contract Year, the Carrier will provide benefits in the amount of the percentage specified in item 32 of the Schedule to be applied to the Covered Dental Expenses for which benefits are payable under the preceding Section A, Subsections 1, 2, 3, 4, or 5, provided payment was made under item 2, above, for the third successive Contract Year. Section C [- DEDUCTIBLE If item 33 of the Schedule is indicated "Applied For," a deductible amount as indicated in item 36 of the Schedule shall apply and must be satisfied before any benefits become payable; pro- vided, however, if item 34 of the Schedule has been indicated, no deductible shall apply to Orthodontic Benefits, or if item 35 of the Schedule has been indicated, no deductible shall apply �. to Basic Benefits. The Deductible shall apply to each Participant for each Benefit Period. If benefits are payable on an indemnity basis, the deductible shall be satisfied on the basis of the first Covered Dental Expenses incurred by a Participant in a Benefit Period and shall be subtracted from amounts of f benefits otherwise payable under Section A, Subsections 1, 2, 3, 4, or 5 of this Article V. If L benefits are payable on the basis of Usual, Customary and Reasonable charges, the deductible shall be satisfied on the basis of the first Covered Dental Expenses incurred by a Participant in a Benefit Period which would be payable otherwise under Section A, Subsections 1, 2, 3, 4, or 5 of this Article V, and notwithstanding the wording of such subsections, benefits shall be _ based on the Covered Dental Expenses incurred in a Benefit Period in excess of the Deductible. The Deductible for an Employee and all of his Dependents shall be deemed to be satisfied for the remainder of the Benefit Period when the Employee and two or more Dependents, or three Dependents, have satisfied their Deductibles. The Usual, Customary and Reasonable charge for any Covered Dental Expenses ARTICLE V— DENTAL BENEFITS PROVIDED (Continued) incurred during the last three (3) months of a Benefit Period, and applied toward satisfaction of the Deductible for such Benefit Period, may be applied toward satisfaction of the Deductible for the next succeeding Benefit Period. Section D PREDETERMINATION If a Course of Treatment can reasonably be expected to involve Covered Dental Expenses of more than $100.00, and the payment is based on Usual, Customary and Reasonable charges, a description of the procedures to be performed and an estimate of the Dentist's charge must be filed with and predetermined by the Carrier prior to the commencement of treatment. If Predeter- mination is not obtained in advance of treatment, the Carrier will unilaterally determine benefits applying alternate plans of treatment when applicable. Section E MAXIMUM BENEFITS PAYABLE If item 37 of the Schedule is indicated "Applied For," the maximum amount payable under this contract for any one Participant during any one Benefit Period shall be indicated in item 38 of the Schedule. The provision of this section shall not apply to Section A, Subsection 6, Orthodontic Benefits. I l_ l_ L Form No. 2817 2817.000-AL679 ARTICLE VI — LIMITATIONS AND EXCLUSIONS The benefits of this contract are not available for any Covered Dental Expenses: A. Received or rendered through or in Veterans Administration facilities; any dental proce- dures for which benefits are or could upon proper claim be provided under the Workers' Compensation law, or any other present or future laws enacted by the Legislature of any state, or by the Congress of the United States, or the laws, regulations or established proce- dures of any county or municipality; provided, however, that the provisions of this Section A shall not be applicable to any coverage held by the Participant for Dental expenses which is written as a part of or in conjunction with any automobile insurance policy; B. Resulting from disease contracted or injuries sustained as a result of war, declared or undeclared, or any act of war; C. Rendered primarily for cosmetic purposes, except for services rendered for correction of defects incurred through traumatic injuries sustained by the Participant while covered hereunder and excepting Orthodontics; nor for procedures not dentally necessary; D. For which a benefit is not specifically listed in Article V and indicated as "Applied For" in the Schedule, or for procedures for which the American Dental Association has not approved a specific procedure code; E. Received or rendered for consultation purposes; F. For replacement of dentures, removable or fixed prosthesis, and dental restorations con- taining gold or platinum due to theft, misplacement or loss; G. For replacement of dentures, removable or fixed prosthesis, and dental restorations con- taining gold or platinum within five (5) years after receiving such dentures, prosthesis or restorations; _ H. For any full-mouth x-ray rendered within three (3) years from the date of the Participant's last full-mouth x-ray. Any bitewing x-ray or prophylaxis rendered within six (6) months of the previous bitewing x-ray or prophylaxis. I. For which an optional technique of treatment or procedure carrying a lesser fee is payable under this contract; J. For personalized complete or partial dentures, overdentures and their related procedures, - or other specialized techniques not normally taught in regular dental school classes; K. Rendered before the effective date of a Participant's coverage or after termination of coverage; L. For appliances, restorations, or special equipment used to increase vertical dimension, correct or determine proper occlusion except as provided for in Article V, Section A, Sub- section 6; or to correct temporomandibular joint dysfunction or pain syndromes; M. For the administration or cost of drugs and/or gases used for sedation or as an analgesia; L N. For which benefits are otherwise provided under Hospitalization, Medical-Surgical, or Prescription Drug Expense Coverages; O. For treatment by other than a Dentist, except that x-rays, scaling or cleaning of teeth and topical application of fluoride may be performed by a licensed dental hygienist if the treatment is rendered under the supervision and guidance of the Dentist; P. For veneers or similar properties of crowns and pontics placed on or replacing second and third molar teeth; Q. For prosthetic devices (including bridges), crowns, inlays, onlays, and the fitting thereof, Iwhich began before the effective date of the Participant's coverage hereunder; L_ Form No. 2819 2A19_oof�-Al_679 f is •swao;aouejnsui Cue;o uoi;aidwoo ao;ao;si;uap a y;inn;isin palnpagos e dooM o; aanlie; ay; woj; 6ui;insai a6jego a io; ;oei;uoo siy; aapun ;i;auaq ou si aaayl •y;aa;;o 6ui;uijds aoj •,k :s;ueldwi joj •X :wej6oad boa;uoo anbeld a ao `suoi;ona;sui Aie;aip `s;ueleas JOA .M `uoilejoisai je;uap a;eoildnp jo soomidde a;eoildnp jay;o `aoinap of;ay;soid a;eoildnp a aoj •n !uoi;eioossy je;uaa ueoiaawy ay;;o pounoo e Aq panoidde Alln; ;ou ao ajn;eu ui je;uawiaadxa aae goigm sailddns ao saoinaas ao; sa6aeyo 6uipnioui `aoi;owd je;uap ;o spiepue;s paldaooe ;aaw ;ou op yoigm sailddns jo saoinaas JOJ -n '96eaanoO Ie;uaa siy; ;o aouasqe ay; ui apew aq p1nom a6ieyo ou goigm ao; Lao Aed o; pa;e6ilgo Allebal ;ou si aaAoldwe ay; yoigm jo; jo apew si a6aeyo ou goigm aoj •1 'j@Aoldwe sjuai;ed ay;Aq pauie;uiew Jo papinoid Al!l!oe; jejiwis ao `oiuip `;uaw;aedep jeoipaw a g6noay; paaapueu •S !eoueildde oquopoy;ao ue ;o Aiedai ao;uawaoeldai aoj •a (penulluo0) SNOIS(113X3 aNd SNOIldllWll — IA 31011ad i ARTICLE VII -TERMINATION OF COVERAGE A. The coverage of all Participants hereunder shall automatically terminate when this contract is terminated in any manner, as follows: 1. By cancellation on any premium due date, at the request in writing of the Employer furnished to the Carrier at its Home Office, not less than thirty (30) days in advance; 2. By default in premium payment, subject to the grace period provided in Article III; 3. By failure of the Employer to maintain enrollment of its Employees hereunder at a level of at least seventy-five percent(75%) of the total eligible number, with a minimum enrollment of twenty-five (25) Employees provided that the Carrier shall first notify the Employer of such enrollment deficiency, and provided further that the contract shall not terminate if, within the thirty (30) days following such notification, the deficiency is remedied. In the event of failure to remedy the enrollment deficiency in such case, the date of termination 1 of this contract shall be the last day of the contract month following the month in which the deficiency notification is furnished. -� B. The coverage of any Employee and his Dependents included hereunder shall automatically terminate upon: 1, The last day of the last period for which his portion of the group premium is paid to the Carrier; { 2. The effective date of an amendment to this contract which terminates the coverage of any class of Employees to which he belongs. C. The coverage of any Dependent of an Employee included hereunder shall automatically termi- nate at the end of the contract month in which such Dependent ceases to be a Dependent as defined in Article I,Section C, of this contract. D. The Carrier will refund to the Employer the portion of the premium theretofore paid in advance for coverage of a Dependent whose coverage terminates in accordance with the provisions of Section C, above; provided, however, that in case of termination on account of marriage, the refund will not be made as to any period before the Carrier is actually notified of the marriage. E. Under no circumstances shall the Carrier be obligated to notify any Participant of the termina- tion of this contract or of his coverage hereunder. F. Notwithstanding the above provisions of this Article VII, if the Employer is paying an Employee's premiums in whole or in part pursuant to the terms of a collective bargaining agreement and in the event of cessation of work as the result of a labor dispute by its Employees who are members of the bargaining unit, coverage under this contract for such Employees and their Dependents hereunder shall terminate on the last day of the Contract Month in which such cessation of work began; except that coverage under this contract may be continued for such Employees and Dependents for a period of up to six (6) additional Contract Months, provided that for each such additional Contract Month: 1. Coverage of at least seventy-five percent (75%) of the Employees, who are members of the bargaining unit and who cease working due to the labor dispute, is maintained; and 2. A single payment for the premiums due from such Employees is remitted within the grace period for such premium payment. The Carrier reserves the right to adjust premium rates for such Employees which shall be payable for such additional Contract Months. 1 Form No. 2820 2820.000-AL679 ARTICLE VI11 - GENERAL PROVISIONS 1 A. CONTRACT; AMENDMENTS: 1. This contract and the Application of the Employer hereof, a copy of which is attached hereto, and the applications of Employees shall constitute the entire contract. All state- ments made by the Employer or by the Employees covered shall be deemed representa- tions and not warranties, and no statement made by any Employee covered shall be used in any contest or in defense of a claim hereunder unless a copy of the instrument contain- ing the statement is or has been furnished to such person or to his beneficiary. 2. This contract may be amended or changed at any time, subject to the laws of the jurisdic- tion in which it is delivered, without the consent of the Employees covered hereunder or of their beneficiaries, by written agreement between the Employer and the Carrier. Only the President, a Vice-President, the Secretary, or an Assistant Secretary of the Carrier has the power to change, modify, or waive the provisions of this contract, and then only in writing done at the Home Office. The Carrier shall not be bound by any promise or repre- sentation heretofore or hereafter made by or to any agent other than specified above. B. INCONTESTABILITY: This contract shall be incontestable after two years from date of issue except for nonpayment of premiums. C. TIME LIMIT ON CERTAIN DEFENSES: After one year from the effective date of coverage for any Employee no misstatements, except fraudulent misstatements, made in his application for coverage shall be used to void his coverage or to deny a claim for benefits on account of Dental services rendered after the expiration of such one-year period. D. REINSTATEMENT: If default be made in the premium payments for this contract, the subse- quent acceptance of such premium by the Carrier or any of its duly authorized agents shall fully reinstate the contract. E. NOTICE OF CLAIM: The Employee shall give or cause to be given written notice to the Home Office of the Carrier at Dallas, Texas or its duly authorized agent within thirty (30) days or as soon as reasonably possible after any Participant receives any of the services for which benefits are provided herein. F. CLAIM FORMS: The Carrier will furnish to the Employee and/or the Participant's Dentist, upon receipt of a notice of claim or prior thereto, such forms as are usually furnished by it for filing proof of loss. If such forms are not furnished within fifteen (15) days after the giving of such notice, the Participant shall be deemed to have complied with the requirements of this contract as to proof of loss upon submitting, within the time fixed in the contract for filing L proofs of loss, written proof covering the occurrence, the character and the extent of the loss for which claim is made. G. PROOFS OF LOSS: Written proof of loss must be furnished to the Home Office of the Carrier at Dallas, Texas, by the Employee within ninety (90) days after any Participant hereunder receives services for which benefits are provided herein. Failure to give notice or furnish proof within the time specified shall not invalidate any rights if it shall be shown not to have been reasonably possible to give such notice or furnish such proof, and that it was done as soon as was reasonably possible, and in no event, except in the absence of legal capacity, later than one year from the time proof is otherwise required. H. TIME OF PAYMENT OF CLAIMS: Benefits payable under this contract for any loss will be paid immediately upon receipt of due written proof of such loss. 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GROUP LIFE & HEALTH INSURANCE COMPANY W. F. Hac meister, President w I R&strr J Srocx No. 9d60.000•-AL1279 This Application Is Hereby Made to i GROUP HOSPITAL SERVICE, INC. Dallas, Texas by the Employer named below for an Experience Rated Group Dental Contract, Form No. GDC-2, in accordance with the stipulations set out herein. The Contract Number shall be 65816 SCHEDULE OF SPECIFICATIONS XXX in any space means Coverage factor applicable COVERAGE FACTORS BASIC BENEFITS: ADDITIONAL BASIC BENEFITS: Item Item Number Number 1. Applied For =Not Applied For 6. D-� Applied For Not Applied For 2. ® Basis of Payment — Usual, 7. ® Basis of Payment— Usual, Customary and Reasonable Customary and Reasonable 3. 100% 90% ©80% 8. 0 100% 90% ®80% - 70% 60% 50% 70% 0 60% 0 50% 0 Other Specify _ % Other Specify % j 4. 0 Basis of Payment — Schedule of 9. 0 Basis of Payment — Schedule of )i Indemnity Allowance Indemnity Allowance 5. High 0 Medium 0 Low 10. 0 High 0 Medium 0 Low PROSTHETIC BENEFITS: PERIODONTIC BENEFITS: Item Item Number Number 11. 0 Applied For Not Applied For 16. ®Applied For 0 Not Applied For 12. 0 Basis of Payment — Usual, 17. ®Basis of Payment — Usual, Customary and Reasonable Customary and Reasonable 13. 100% 0 90% 80% 18. 100% 90% ®80% 0 70% 0 60% 0 50% 70% 60% 50% Other Specify % 0 Other Specify % 14. 0 Basis of Payment — Schedule of 19. 0 Basis of Payment — Schedule of Indemnity Allowance Indemnity Allowance 15. 0 High Medium Low 20. 0 High Medium Low IForm No. GDC-2-App Page 1 Stock No. 2822.000-N679 CROWNS, INLAYS AND ONLAYS BENEFITS: ORTHODONTIC BENEFITS: { Item Item 1 Number Number 21. 0 Applied For Y� Not Applied For 26. LW Applied For Not Applied For 22. Basis of Payment — Usual, 27. Usual, Customary and Reasonable Customary and Reasonable J 0 23. � 100% �90% 0 80% 50% 60% 70% 60% 50% Other Specify % � � � 28. Lifetime Maximum Benefit Other Specify _ % $500 $600 ®$700 24. Basis of Payment — Schedule of Indemnity Allowance 0 Other Specify $ —_ 25. 0 High Medium Low 1 INCENTIVE—USUAL, CUSTOMARY AND DEDUCTIBLE: REASONABLE Item —� Item Number Number 33. ®Applied For 0 Not Applied For 29. 0 Applied For ® Not Applied For 34. �; Does not apply to Orthodontic Benefits 30. Percentage for second Contract Year 35. 0 Does not apply to Basic Benefits � 10% 0 Other 36. 0$25 a�ff$50 $75 Specify % 0 Other Specify $ 31. Percentage for third Contract Year 0 20% Other MAXIMUMS: Per Benefit Period Item Specify % Number 37. ®Applied For Not Applied For 32. Percentage for fourth Contract Year 38. $500 �—=$750 0$1000 30% =Other 0 Other Specify $__ Specify % I iForm No. GDC-2-App Page 2 Stock No.2823.000-N679 ELIGIBILITY REGULATIONS: Persons eligible to apply for coverage under the contract shall be the Employees of the Employer named below who have been continuously employed for not less than __ _ ___60__ _ days. No period of continuous �( employment shall be required for Employees otherwise eligible on the Contract Date D Yes LX No. 1 EFFECTIVE DATES: The effective dates of individual applications are to be handled under the terms of: Standard Option L Option I i� Option II Other (See Special Provisions) ********END OF SCHEDULE OF SPECIFICATIONS**""" CONTRACT DATES:The Contract Date is_ _—_ December 1 19 S0 _. The first contract anniversary shall be J _ ovember 1 1g81, whether or not the two dates are separated ___ —.-- by twelve months. MINIMUM ENROLLMENT REQUIREMENTS: The Employer certifies that -- 932 _ Employees are eligible to make application for coverage at the date of this group application, and agrees that at least 75% of that number (25 minimum) must make application for coverage before the contract date, otherwise this application shall be deemed to have been withdrawn. PREMIUMS: The Employer will provide payroll deduction facilities for the Employee's portion of the premium and make consolidated group premium remittances. The following shall be the initial monthly premium rates: Employee, spouse Emoloyee Employee Employee and Employee and and dependent child Only and Spouse Dependent child Dependent children or children s 1.95 s 4.10 s5.96 s5.96 $ 5.10 1 The above monthly premium rates shall be subject to change on the first contract anniversary. As of the Contract Date, the amount of Employer contribution is: total employee rate with no contribution toward dependents. j SPECIAL PROVISIONS: The following stipulations shall be considered a part of this application: The contract and the coverage provided thereunder shall become effective on the Contract Date stipu- lated above under Contract Dates, provided that (1) this application is executed in duplicate; (2) payment of the first month's premium is received by Group Hospital Service, Inc.; and (3) in the event of any alteration of this application, such alteration is accepted in writing by Group Hospital Service, Inc. Employer: City of Wichita Falls Wichita Falls Texas (City and State) by uart(si `l!19;nCj't�y Manager Signed at ! '�` Witness: On — 19 Representative of the Cartier f Form No. GDC-2-App Page 3 Stock No.2824.000-N679 This agreement made and entered into this the day of November, 1980 , between the City of Wichita Falls, Texas and Marshall and Stevens Incorporated, WITNESSETH: Whereas , Marshall and Stevens Incorporated has submitted to the City of Wichita Falls a proposal dated September 25, 1980, to conduct certain appraisal services for the City of Wichita Falls for a fee of $39 , 000; and, Whereas , Marshall and Stevens Incorporated has made an alternative proposal whereby City personnel will conduct the inventory of land and equipment, which will reduce the fee from $39, 000 to $26 , 500 . Now, therefore, in consideration of the mutual covenants to be kept and performed by both parties, the parties hereto do hereb�7 agree as follows : Such proposal by Marshall and Stevens Incorporated to the City of Wichita Falls, dated September 25 , 1980, to perform the services therein set out for a fee of $39 , 000, is hereby accepted by the City of Wichita Falls. IN WITNESS WHEREOF , the parties have caused this agreement to be executed as of the day and year first set out above. Marshall and Stevens Incorporated BY: City of Wichita Falls, Texas ATTEST: BY: City Manager City Clerk