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173 Please print or type. CENTRAL TEXAS HEALTH PLAN 3307 Northland Drive, Suite 300 Austin Texas 78731 (512) 454-6771 APPLICATION FOR . MASTER GROUP CONTRACT £'f--Hl ~.() "A I( BENEFIT CONTRACT DESCRIPTION GROUP # 20362 A2X GM-12 The Enrolling Unit named below hereby makes application to the Central Texas Health Plan for a Master Group Contract to be issued as follows: 1. Name of Enrolling Unit: CITY OF SAN NARCOS 2. Address (Number& Slreet) 630 E. Hopkins (Cily) San Marcos (State) Texa~ (Zip) 7Rññh Telephone: 512-353-4444 Mailing address (if different from above): (Number&Slreet) Same 3, Legal Status: Corporation Partnership X Other (Specify) City Government 4. Nature of Business or Industry: C i t Y (City) (State) (Zip) Proprietorship Trustee Employer Taxpayer 10 Number 239-263-787105 5. Subsidiaries: The following subsidiaries, affiliates or other related organizations will be included under the Master Group Contract None 6, Eligibility: Description of eligible employee: Employee: All full-time employees working 20 or more hours a week. 30 days following date of hire. New hires effective Dependents: (as defined in MGC) Spouse, unmarried dependent children to age 19; 23 if full-time student. Excluded persons or groups: Temporaries, seasçmal emp 1 oyeeR 7. Enrollment Period: The Initial Eligibility period will not exceed t hi r t y (30) days. 8. Effective Date: The Master Group Contract wili be delivered in and governed by Ihelawsolthe StateofTexas and shall take ertect on An gill t 1, 19 ---.a.a,utonly if this Application is accepted and signed bylhe Central Texas Health Plan. Annual Renewatdaleofthiscontractshall be ugus t 1, 1989 The Health Services Fees specified on this Application are guaranteed until J u 1 y 31. 1 989 . 9. Health Services Fees: All Health Services Fees shall be paid by the Enrolling Unit to the Central Texas Health PIaR- at its Austin office on or before each due date. The first Health Services Fee for the Master Group Contract is due 10 days aller delivery ot the lirst billing, subsequent Health Services Fees are payable monthly in accordance with the terms specified in the Master Group Contract. 10. The EnroJling Unit will contribute * toward thecostofthe employee's monthly Heaith Services Fees and dent's monthly Health Services Fees, 11. Please name the Group Administrator ot your health benefits plan Title * toward the cost of the depen- Ms. Virginia May. Risk. Safety. Benefits Manager Phone Number 512-353-4444 Ext. The Enrolling Unit hereby agrees and understands that the Master Group Contract is issued based on this application and that the acceptance of the Master Group Contract constitutes agreement to all terms and conditions of this Application and the Master Group Contract. A copy of this Application shall be attached to and made a part ot the Master Group Contract ued to the Enrolling Unit. on the of (Month) ,19 (Year) Signed at (Day) Title A.C. Gonzales City Manager Rodney P. Spencer Executive Vice President Title FOR CTHP OFFICE USE ONLY -- Approved - Disapproved by Master Group Contract Number A2X GM - 12 Date Addendum Attached AÞ1/TOC-12, THP-C-AJ11, MHR I/B8, CT87.57 1/88, CT87.35 1/88, THPEMRG 9/87, GREV/ERS 2/88, THPRX 10/87, GHR7, MM-OO4 ASLP-2 GAI-2 10184 * The dollar amount which makes the benefit programs equitable.