R99-108 AUTHORIZING APPLICATIONS

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� �1. Enrollment: Special Enrollment: An Eligibie Person may apply for coverage, Family coverage or add dependents within thirty-one (31) days of a qualifying event'rf he/she did not apply prior to his/her Eligibility Date or when eligible to do so. Such person's Coverage Date, Family Coverage Date,and/or dependent's � Coverage Date will be the effective date of the qualiiying event or, in the event of Special Enrollment due to termination of previous coverage, the date of application of coverage. Late Enrollment: An Eligible Person may apply for coverage, Family coverage or add dependents , if he/she did not apply prior to his/her Eligibility Date or did not apply when eligible to do so. Such person's Coverage Date, Family Coverage Date, and/or dependent's Coverage Date will be a date mutually agreed to by the Claim Administrator and the Employer. Open Enrollment An Eligible Person may apply for coverage, Family coverage or add dependents if he/she did not apply prior to his/her Eligibility Date or did not apply when eligible to do so, during the Employer's Open Enrollment Period. • Specify Open Enrollment Period: the 30th date after eligibility date Such person's Coverage Date, Family Coverage Date, and/or dependent's Coverage Date will be a date mutually agreed to by the Claim Administrator and the Employer. Such date shall be subsequent to the Open Enrollment Period. 12. Extension of Coverage due to Temporary Layoff, Leave of Absence or Disability shall be none. However,benefits shall be extended for the durafion of an Digible Person's leave in accordance with the Family and Medical Leave Act of 1993,as amendec� IN WITNESS WHEREOF,the Employer hereby duly executes this Adoption Agreement and the Plan this �3thday of Ju1y , 1 g 99 , For: city of Decatur By; James L. Williams, Jr. Print a By: � Signature TItl2: City Manager ATTE : � , �L2� TItIE: City Clerk