Okaloosa County BOCC — December 16, 2014 — Group Ins Amendment Standard Vision 2014 — reading text

TreStandard ¥ Request for Group Insurance Amendment Standard Insurance Company 900 SW Fifth Avenue Portland, OR 97204-1282 Employee Benefits Consultant: Jarod Hayer . Employee Benefits Service Representative: Alison Brogan Employee Benefits Sales and Service Office: Tampa Employer Name: Okaloosa County Board of County Commissioners Group Number: 649032 As an authorized.representative of the Employer, I request that Standard Insurance Company (“The Standard”) amend the above Employer’s coverage under the Group Policy to make the following change(s): , e Change Eligibility Waiting Period for “All Others” to first of the month coinciding with or next following 30 days as a member. ¢ I request that the amendment become effective on 10/1/2014. I understand that the amendment will not become effective unless approved and issued by The Standard. I request that the amendment be approved by The Standard subject to The Standard’s usual underwriting requirements, including, if applicable, Evidence of Insurability or a Pre-existing Condition provision. I understand that the amendment, if approved by The Standard, will be issued in the policy language customarily used by The Standard. I understand that any increase in Insurance for a Member who is not Actively At Work all day on the Member’s last regular work day before the scheduled effective date of the amendment will be deferred until the first day after the Member completes one full day ~ of Active Work. - I request that the amendment, if approved and issued by The Standard, become effective by its terms without any further acceptance by the Employer, and that a copy of this Request for Group Insurance Amendment form be attached to and made a part of the amendment. Sign Name: . Title: Chairman Authorized Representative : Print Name: Charles K. Windes, Jr. pate: Standard Online Amendment Request 10/27/2014 4:27 PM