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HomeMy WebLinkAboutContract CAG-19-318 . U m ,r; c r1 NIOo 00 co C 0 0 yj 0 0 NI U1 0 cY l0 C1 (N ,__•I -p 23 :El VI M t0 N a)O rn • M0 M u1 0 1-1 .—t? ON >-* N O c-1 r I -V1- C CQ th ill 1/1. O O Q ta.cO E iQ (o O O -C O- U U E a.) cc m (0 ate-+ U C c-1 N N M N• o C N O — N u1 Lfl CO O E L > M 0 0 M lD M a >,- y/T ,-i .--I ri t/T In C O C aJC O 0_ -C/1- VI1J a) L > E U U 00 C ra U Q -O +'CO �--I NJ (V Ol M CO Cr 0 a (0 a! "p l0 111 V) N O O C E N N M M t-I o N co U > M O O a th c-I .-t e-I VT !T -VT IA- 4" O 0 N _ C CU 0 cc C C ioN co co N O O O N (0 0 a. i C 0_ Ni co CO O 0) !T --1 c,t c -1 N NU N a tiT tn. v). O (N) N r- L 0 D C V 0 D E N O 0 ` O = ^ C c '47, 4_, a _ `` _ 0 0 ro O LO i Fp�- VI Q U +� 4--. C O . c 0 0 ,O U 0C ea C C 3 `_^ '- F 0 (o a to N in N 0 0 L a1 O -O Q O 00 p `� CO Q F) m - _ U C I— a1 +, i Q y - 0 aJ O C OA o� O O L \ > •C CD Q (C C U 'C U ,-' y 3 l0 i ,W a C 0 CU C " 0 E V, W C J 0 > 0 J JO U W CC W 1— J < U d C = ^ co co N C o .-i r-I N a o i C d N 00 00 O +4-' 0.) t!? e,-i N N U a in- in- .n O ^i N I- 0 D C v d _ a c E H O o o -~ O = >. c C 'y = O 1� L V .0 v a1 (II N a Q- +J O_ Q .Q C C = v - O U c C C C L 1- 04. OL CIA VI H O N -O °- O pp p v- co 6 Q ) m 0 4_ - U C '� �, +, C L Q �, - 0 N pp p C pp C N Ca 0 O L 0) N � �, O C -� C) co 3 c i a) a C y GA E t a) C C v 0v v := 0 D X v 'x 0 = C U CL > 0 _+ U w v CC w F- -� < & 2 2 & % / 00 C e o 2 p % ,-I w D § / ƒ 0 e 0 U t \ m m 7 o esJ q ' 0 2 \ c o ƒ E C 3 / _ 4 � % % / » _ \ \ % O % ƒ u _ coJ = D . = « 2 J J = 3 \ SI p i \ / E 0 E \ � � \ 2 = E c \ ._ \ \ / D n \ _ p g 2 / ± u \ \ u =0,0 o f k g b _ 2 \ 7 = / : - 0 \ C ( © > j © 0 0 \ on [ \ \ 2 E co ƒ S O > e S c u » u I- -J < Symetra Life Insurance Company 777 108th Avenue NE, Suite 1200 S Y M E T R A Bellevue,Washington 98004-5135 RETIREMENT I BENEFITS I LIFE Application for Group Insurance Name of Applicant: City of Renton Address: 1055 South Grady Way (Street) Renton WA 98057 (City) (State) (Zip) applies to Symetra Life Insurance Company,for: ❑ Group Short Term Disability Insurance ❑✓ Group Long Term Disability Insurance ❑✓ Group Term Life Insurance If Symetra Life Insurance Company (Symetra) approves this application, the policy(ies) indicated above will be issued. The applicant agrees that by signing this application it accepts the policy issued pursuant to the proposal dated September 19, 2019 This application supersedes any previous application. It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits. Signed at(City) Renton , (State)WA Date signed: 4% s/< City of Rent. Attest: g 11W J son A.., pclerk y Title Mayor or .Denis L.aw �'� .•�`"�„Ilan+r Q ''�, * ' SEAL AL = i` Producer Name(printed) err 26 , Producer Signature 04,p "11""`,"� o:0 .�� Resident Licensed Producer where required by law pP.4TEDSt,'•••`� Instructions: (1) Sign and return to Symetra. (2) Retain copy with your policy. Symetra and the Symetra Financial logo are registered service marks of Symetra Life Insurance Company. LGC-10033/WA 04/12